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A  SYSTEM  OF  LEGAL  MEDICINE. 

VOLUME  II. 


A  SYSTEM 


OF 


LEGAL  MEDICINE 

BY 

ALLAN   McLANE  HAMILTON,  M.  D. 

CONSULTING  PHYSICIAN   TO  THE  INSANE   ASYLUMS  OF  NEW-YORK  CITY,  ETC.,  ETC. 

AND 

LAWRENCE  GODKIN,  ESQ- 


OF    THE   NEW-YORK   BAR 


WITH  THE  COLLABORATION  OF 

PROF.  J  AM  ES  F.  BABCOCK,  LEWIS  BALCH .  M .  D. , 

JUDGE    S.    E.    BALDWIN,    LOUIS    E.    BINSSE,    ESQ.., 

C.  F.  BISHOP,  ESQ..,  A.  T.  BRISTOW,  M.  D.,  B.  F.  CARDOZO,  ESQ.-, 

C.  G.  CHADDOCK.  M.  D.,  A.    F.  CURRIER,   M.  D.,  C.   L.    DANA,  M.  D.,  GEO. 

RYERSON  FOWLER.  M.  D.,  W.T.GIBB,  M.  D.,  W.  S.  HAINES,  M.  D.,  F.  A.  HARRIS.  M.  D., 

W.  B.  HORNBLOWER,ESQ..CHAS.JEWETT,  M.  D.,  P.C.  KNAPP,  M.  D.,  R.  C.  McMURTRIE, 

ESQ..,  C.  K.  MILLS,  M.  D.,  J.  E.  PARSONS,  ESQ..,  C.  E.  PELLEW,  E.  M., 

JUDGE  C.  E.  PRATT.  W.  A.  PURRINGTON,  ESQ.-,  B.  SACHS,  M.  D., 

F.  R.  STURGIS,  M.  D.,  BRANDRETH  SYMONDS,  M.  D., 

V.  C.  VAUGHAN,  M.  D. 


ILLUSTRATED 
VOLUME  II 


NEW-YORK 

E.  B.  TREAT,  5  COOPER  UNION 

1894 


{ 


Copyright,  by 

E.  B.  Treat,  New  York. 

1894. 


All  rights  reserved. 


LIST   OF   COI^TEIBUTOES. 


VOLUME    II. 


SIMEON  E.  BALDWIN,  LL.D.,  one  of  the  Judges  of  tlie  Supreme 
Coiu't  of  the  State  of  Connecticut ;  Professor  in  the  Law  Department 
of  Yale  Colleg-e. 

LOUIS  E.  BINSSE,  of  the  New  York  Bar. 

CHARLES  GILBERT  CHADDOCK,  M.D.,  Professor  of  Diseases  of  the 
Nervous  System,  Marion-Sims  College  of  Medicine,  St.  Louis,  Mo. ; 
Nem'ologist  to  Rebekah  Hospital ;  formerly  Assistant  Medical  Super- 
intendent of  the  North  Michigan  Asylum. 

ANDREW  F.  CURRIER,  M.D.,  Gynecologist  to  Outdoor  Department, 
Bellevue  Hospital. 

CHARLES  L.  DANA,  A.M.,  M.D.,  Professor  of  Nervous  and  Mental  Dis- 
eases in  the  New  York  Post-Graduate  Medical  School  and  in  Dart- 
mouth Medical  CoUege;  Visiting  Physician  to  BeUevue  Hospital; 
Neurologist  to  the  Montefiore  Home  and  to  the  Out-Patient  Depart- 
ment, BeUevue  Hospital ;  Ex-President  of  the  American  Neurological 
Association  and  of  the  New  York  Neurological  Society;  and  Presi- 
dent of  the  Practitioners'  Society  of  New  York  City. 

GEORGE  RYERSON  FOWLER,  M.D.,  of  Brooklyn,  N.  Y.,  Surgeon  to 
the  Methodist  Episcopal  Hospital ;  to  St.  Mary's  Hospital ;  Considt- 
ing  Surgeon  to  the  Relief  Hospital  and  to  the  Nor^v^egian  Hospital ; 
Examiner  in  Siu-gerv,  State  Board  of  Medical  Examiners. 

LAWRENCE  QODKIN,  of  the  New  York  Bar. 

5 


6  LIST   OF  C02iTBIBVT0RS. 

ALLAN  McLANE  HAMILTON,  M.D.,  Consulting  Physician  to  the  In- 
sane Asyhims  of  New  York  City ;  Consulting  Neurologist  to  the  Hos- 
pital for  Ruptured  and  Crippled  and  to  the  Hospital  for  Nervous 
Diseases. 

WM.  B.  HORNBLOWER,  of  the  New  York  Bar. 

CHARLES  JEWETT,  A.M.,  M.D.,  SC.D.,  Professor  of  Obstetrics  and 
Pediatrics  in  the  Long  Island  College  Hospital;  President  of  the 
New  York  Obstetrical  Society  and  President  of  the  G-ynecological 
Society ;  Corresponding  Member  of  the  British  Gynecological  Society. 

PHILIP  COOMBS  KNAPP,  A.M.,  M.D.,  Instructor  in  Nervous  Diseases 
at  Harvard  Medical  School. 

CHARLES  K.  MILLS,  A.M.,  M.D.,  Professor  of  Mental  Diseases  and 
of  Medical  Jurisprudence  in  the  University  of  Pennsylvania ;  Profess- 
or of  Diseases  of  the  Mind  and  Nervous  System  in  the  Philadelphia 
Polyclinic;  etc. 

JOHN  E.  PARSONS,  of  the  New  York  Bar. 

CALVIN  S.  PRATT,  one  of  the  Justices  of  the  Supreme  Court  of  the 
State  of  New  York,  and  Lecturer  upon  Medical  Jurisprudence  at  the 
Long  Island  Hospital  College. 

B.  SACHS,  A.M.,  M.D.,  Professor  of  Mental  and  Nervous  Diseases  in 
the  New  York  Polyclinic ;  Consulting  Neurologist  to  the  Italian  Home 
and  to  the  Montefiore  Home  for  Chronic  Invalids. 

GEORGE  De  FOREST  SMITH,  M.D.,  of  New  York. 

FREDERICK  R.  STURGIS,  M.D.,  one  of  the  Visiting  Surgeons  to  the 
City  Hospital,  Blackwell's  Island. 


CONTENTS   OF  VOLUME   II. 


PAGE 

Duties  and  Responsibilities  of  Medical  Experts 13 

wm.  b.  hoknblowek. 

Insanity  in  its  Medico-Legal  Bearings 19 

ALLAN  McLANE   HAMILTON,  M.D. 

Mental  Responsibility  of  the  Insane  in  Civil  Cases 169 

CALVIN   S.  PEATT. 

Insanity  and  Crdie 175 

B.  SACHS,  a.m.,  M.D. 

On  the  Relations  of  Mentai.  Defect  and  Disease  to  Crdiinal 
Responsibility 217 

louis  e.  binsse. 

Aphasli  and  other  Affections  of  Speech 259 

charles  k.  mills,  m.d. 

The  TRAU5L4.TIC  Neuroses  :  being  a  Description  of  the  Chronic 
Nervous  Disorders  that  follow  Shock  and  Injury 297 

CHARLES  L.  DANA,  A.M.,  M.D. 

The  Effects  op  Electric  Currents  of  High  Power  upon  the 
HiBL^N  Body 363 

ALLAN  McLANE   HAMILTON,  M.D.,  and  GEORGE  De  FOREST  SMITH,  M.D. 

Accident  Cases „ 377 

lawrence  godkin. 

Mental  Distress  as  an  Element  of  Da:\l\ge  in  Cases  to  Re- 
cover FOR  Personal  Injuries 385 

JOHN  E.  PARSONS. 
7 


8  CONTEXTS   OF    VOLUME  II. 

PAGE 

Feigned  Diseases  op  the  Mind  and  Nervous  System 391 

PHILIP  COOMBS  KNAPP,  A.M.,  M.D. 

Birth,  Sex,  Pregnancy,  and  DELI^^:RY 417 

ANDREW   F.  CURRIER,  M.D. 

Abortion  and  Infanticide 4G7 

CHARLES  JEWETT,  A.M.,  M.D.,  Sc.D. 

Oenito-Urinary  and  Venereal  Affections   in  their  Medico- 
Legal  Relations 497 

F.  R.  STURGIS,  M.D. 

Marriage  and  Divorce 517 

SIMEON  E.  BALDWIN,  LL.D. 

Sexual  Crbies 525 

charles  gilbert  chaddock,  m.d.  s^  i- 

Surgical  Malpractice 573 

george  ryerson  fowler,  m.d. 

Appendix 631 

Index 681 


LIST   OF   ILLUSTEATIO^^S. 


VOLUME    11. 


PLATES. 

PAGE 

I.  Microscopic  Appearance  of  Brain  of  Epileptic,  showing  Celln- 

lar  Degeneration 71 

II.  Criminals  who  have  become  Insane.     Degenerate  Type 183 

III.  Criminals  by  Reason  of  Insanity 187 

lY.  Hysterical  Hemiplegia,  showing  the  Peculiar  Dragging  of  the 

Foot  337 

Y.  Male  Hysteria,  showing  Characteristic  Physiognomy 345 

YI.  Lnngs  and  Intrathoracic  Organs  of  New-born  Child,  a  A^ictim 

of  Infanticide '473 


WOOD-CUTS   AND   HALF-TONE   ENGRAYINGS. 

Fig.    1.  Sknll  of  Tamping-iron  Case 21 

Figs.  2-4.  Diagrams  iUnstrating  the  Ramifications  of  Fibers  and  the 

Location  of  the  Basal  Sensory  Area  of  the  Brnin 22 

Fig.  5.  Diagram  representing  the  Conrse  of  the  Pyramidal  Fibers. .  23 
Fig.    C.  Diagram  representing  the  Topography  of  the  Cortical  Ai-eas 

of  the  Left  Hemisphere 24 

Figs.  7-10.  Sections  of  the  Cerebrnm  sliowino-  tlie  Association  Fiber 


Systeni 


25 


Fig.  11.  Arterial  Snpply  at  the  Base  of  the  Brain 2G 

9 


10  LIST  OF  ILLUSTRATIOXS. 

PAGE 

Fig.  12.  Male  Sexual  Pei-vert 50 

Fig.  13.  Braiu  of  Mierocephale G7 

Fig.  14.  Physioguomy  of  Chronic  Excited  lusaue  Patieut To 

Fig.  15.  Physioguomy  of  Chronic  Depressed  Insane  Patient 74 

Fig.  16.  Writing  of  a  Paranoiac 75 

Fig.  17.  "Writing  of  an  Educated  Paretic  Dement 7(3 

Fig.  18.  Writing  showing  Deterioration  in  Paretic  Dementia 77 

Fig.  19.  OthaBmatoma,  or  •■  Insane  Ear  " 7$ 

Fig.  20.  Casts  of  Vault  of  Month,  showing  Defects  in  Hard  Palate. .  82 
Fig.  21.  Casts  of  Palates.  sh<)wing  Standard  Types  and  Changes 

found  in  Adolescent  Insanity 83 

Fig.  22.  Fantastic  Decoration  in  Pai"auoia 87 

Fig.  23.  Physiognomy  of  Melancholia 99 

Fig.  24.  Physiognomy  of  Mania 101 

Fig.  25.  Kavachol 184 

Fig.  26.  Head  Configuration  of  Forger , 185 

Fig.  27.  Head  Configuration  of  Bandit 185 

Figs.  28-33.  Types  of  Instinctive  Criminals 186 

Figs.  34—36.  Diagi-ams  showing  Ai-ea  over  which  Cutaneous  Irrita- 
tion produces  Cremasteric  Keflex  Conti'action  and  Knee- 
jerk 314 

Figs.  37,  38.  Ataxiagi-ams 315- 

FiGS.  39.  40.  Visual-field  Limitations 317,  318 

Figs.  41,  42.  Comparative  Size  and  Kelations  of  Brain  and  Spinal 

Cord 32a 

Fig.  43.  Points  of  Exit  of  Cutaneous  Branches  of  Spinal  Nerves. . .  324 
Fig.  44.  Topography  of  Back,  .showing  Relation  of  Points  of  Origin 

and  Exit  of  Spinal  Nerves  to  the  Spinous  Processes 325 

Figs.  45-52.  Diagrams  showing  Distribution  of  the  Sensoiy  Nerves, 

327,  328 


LIST  OF  ILLUSTRATIONS.  \\ 

r.\<.i: 
Fig.  58.  Diagrams  showing  Different  Modes  of  Hysterical  Antes- 

tlicsia 'M(\ 

Figs.  54-5G.  Aiiiestliesia  witii  Hysteria,  and  Lesions  of  the  C'anda 

E({uiiia 34 1 

Fig.  57.  An;i3sthesia  in  a  Case  of  Myelitis 3-12 

Fig.  58.  Diagram  sliowing  Normal  Field  of  Vision  of  Right  Eye  for 

Color  and  Form 343 

Fig.  59.  Same  for  Left  Eye 343 

Figs.  G0-G2.  Examples  of  Hermaphrodism 420-422 

Fig.  G3.  Diagram  showing  Relation  of  Parts  in  Hermaphrodism . . .  423 

Fig.  G4.  Cnrrier's  Case  of  Enlarged  Labia  Minora 424 

Fig.  G5.  Figure  representing  Female  Organs  of  Generation 42.5 

Fig.  GG.  Currier's  Case  of  Double  Uterus 446 

Fig.  G7.  Currier's  Case  of  Tubal  Pregnancy 448 

Fig.  G8.  Diagram  illustrating  the  Enlargement  of  the  Uterus  in 

Pregnancy 454 

Fig.  69.  Showing  Annular  Hymen 529 

Figs.  70,  71.  Showing  Crescentic  Hymens 530 

Fig.  72.  Showing  Hymen  Fimbriatus,  Intact 530 

Fig.  73.  Showing  Ruptured  Hymen  Fimbriatus 530 

Fig.  74.  Showing  Hymen  Sa?ptus,  with  Unequal  Openings 531 

Fig,  75.  Showing  Hymen  with  Posterior  Rudimentary  Septum. . . .  531 
Fig.  76.  Showing  Ruptured  Crescentic  Hymen,  Avitli  Two  Lateral 

Lacerations ...   532 

Fig.  77.  Showing  Circular  Hymen,  Torn  in  Several  Places 532 

Fig.  78.  Showing  Ruptured  Hymen  Saeptus 533 


DUTIES  AND  RESPONSIBILITIES   OF  MEDICAL  EX- 
PERTS. 

BY  WM.  B.  HORNBLOWER. 


One  of  the  most  important  and  striking  de^'^elopments  of  modern  ju- 
risprudence is  in  the  line  of  expert  testimon3^  The  common  law  recog- 
nizes the  right  of  parties  to  call  as  witnesses  those  who  are  specially 
skilled  in  or  familiar  with  any  particular  art  or  science,  in  order  to  ex- 
plain the  meaning  of  words  or  phrases  having  a  pecuhar  meaning  in 
such  art  or  science.  From  this  has  developed  the  practice  of  caUing  ex- 
perts in  mechanics  to  give  opinions  in  patent  cases,  and  experts  in 
medical  science  to  give  opinions  in  cases  involving  medical  questions. 

The  most  important  class  of  cases  in  which  medical  experts  are  called 
to  give  testimony  is  that  involving  the  issue  of  sanity  or  insanity.  Many 
embarrassing  difficulties  have  arisen  in  cases  of  this  kind  as  to  the 
examination  of  expert  witnesses,  and  many  well-founded  objections 
have  been  made  to  the  methods  employed  in  such  examination  in  the 
courts  in  this  country  and  in  England.  Some  of  the  most  sahent  ob- 
jections are  to  the  employing  of  persons  as  paid  medical  counsel  by 
one  side  or  the  other ;  the  examination  of  the  exj)erts  by  hypothetical 
questions  framed  in  the  interest  of  one  side  or  the  other ;  and  the  laying 
down  of  tests  of  sanit}'^  or  insanity  by  the  courts  as  matters  of  law,  in- 
stead of  treating  the  questions  as  pui'ely  medical  ones  to  be  decided  by 
the  weight  of  the  expert  testimony. 

Before  considering  any  of  these  objections  it  is  proper  to  state  in  a 
summary  manner  what  is  the  general  practice  prevailing  in  the  courts  of 
England  and  of  this  country.  To  cite  authorities  in  illustration  of  the 
practice,  or  to  endea\'or  to  differentiate  the  practice  of  the  various  juris- 
dictions, or  to  state  the  limitations  and  exceptions  to  the  rules  laid  clo^vn, 
would  involve  a  treatise.  My  function  is  simply  to  give  results  and  to 
state  the  practice  in  general  as  it  now  exists. 

In  the  first  place,  it  is  a  principle  of  our  jurisprudence  that  the  ques- 
tion of  sanity  or  insanity,  when  it  arises  as  an  issue  in  the  case,  is  to  be 
determined  by  the  court,  or,  if  it  be  a  jury  case,  by  the  jury,  and  is  not 
to  be  decided  by  the  medical  experts.  Again,  the  question  of  sanity  or 
insanity  presents  itself  in  different  shape  in  different  forms  of  litigation, 
and  the  legal  rules  as  to  what  constitutes  sanity  or  insanity  in  the  case 
before  the  court  are  laid  down  by  the  court  f(n*  the  guidance  of  the  ex- 
perts as  well  as  the  guidance  of  the  court  itseK  or  the  jmy. 

13 


14  A   SYSTEM  OF  LEGAL  MEDICIXE. 

Thus,  iu  criminal  trials  where  the  accused  is  defended  on  the  ground 
of  insanity,  the  courts  have  laid  do-wu  certain  rules  of  law  as  to  what 
degree  of  mental  or  moral  obhquity  is  sufficient  to  shield  a  man  from 
punishment  and  to  make  him,  in  a  legal  sense,  irresponsible.  The  com-ts 
have  differed  mdely  as  to  these  tests,  and  no  rule  of  law  with  reference 
thereto  is  universally  accepted  even  now;  but  nevertheless  the  eoiu-ts 
assume  the  right  to  instruct  the  jiuy  as  to  what  does  constitute  sufficient 
insanit}'  to  be  a  defense. 

One  of  the  tests  laid  do^^m  by  some  of  the  courts  has  been  that  defend- 
ant must  have  been  so  far  uncler  the  influence  of  insane  delusion  at  the 
moment  of  committing  the  act  as  not  to  be  conscious  of  right  or  wi-ong. 
This  test  has  the  sanction  of  the  House  of  Lords.  Another  test  laid 
down  is  that  the  defendant  is  responsible  for  his  act  if  he  had  sufficient 
intelligence  to  know  tlie  physical  consecpiences  of  the  act,  and  that  it 
was  a  Avrongful  act  and  in  violation  of  the  law,  whether  he  was  under  the 
influence  of  moral  delusion  or  not.  But  whatever  test  be  adopted,  it 
is  well  settled  in  practice  that  the  court  is  to  declare  the  rule  and  the 
jmy  are  bound  to  accept  it. 

Again,  in  the  trial  of  mil  cases,  the  tests  of  competency  to  make  a 
will  are  laid  down  by  the  coiu-ts.  The  most  usual  rule  laid  down  is  that 
the  testator  was  competent  to  make  a  will  if  he  had  sufficient  intelligence 
to  remember  and  understand  the  nature  of  his  property-,  the  objects  of 
his  bounty,  and  those  having  claims  upon  him,  even  tliough  he  may  have 
been  to  some  extent  mentally  unsound. 

Yer}^  severe  criticism  has  been  indulged  in  by  some,  medical  men  and 
alienists  upon  this  practice  of  laying  down  the  test  of  criminal  responsibility 
and  testamentary  capacity  by  the  courts.  It  has  been  urged  that  the  ques- 
tion of  insanity  is  one  purely  of  medical  science,  and  that  the  tests  of  in- 
sanity should  be  derived  from  the  testimony  of  the  experts,  and  not  from 
the  opinions  of  the  judges.  Tliis  objection  assumes  that  the  issue  is 
purely  one  of  sanity  or  insanity.  There  are,  howevei',  various  degrees 
and  phases  of  mental  unsoimduess.  A  man  may  be  to  some  extent  men- 
tally unsound,  and  yet  he  may  not  be  in  such  a  condition  of  mind  that  as 
between  him  and  the  community  he  should  be  shielded  from  the  conse- 
quences of  criminal  conduct.  So,  too,  a  man  may  have  mental  delusions 
or  weaknesses,  and  yet  not  be  incapable  of  disposing  of  his  property. 
It  would  seem,  therefore,  proper  that  there  should  be  some  general  i-uk'S 
of  law  laid  down  for  the  various  classes  of  cases  where  insanity  is  an 
issue,  and  that  there  should  be  some  guide  laid  down  for  the  instruction 
of  juries  and  judges  in  the  different  classes  of  cases.  At  any  rate,  such 
is  the  practice. 

The  rule  is  thus  stated  by  an  eminent  authority  ("N'^niarton  and  Stille's 
Medical  Jimsprudence,  sec.  193) :  ''AVliile  experts  maybe  called  to  testify 
as  to  states  of  mind  and  conditions  of  health,  it  is  for  the  court  to  de- 
clare whether  such  states  and  conditions  constitute  irresponsibility." 

Another  well-settled  rule  is  that  medical-expert  ^^^tuesses  may  be 
permitted  to  state,  in  connection  with  their  opinion,  as  to  the  sanity  or 
insanity  of  a  person,  based  upon  the  testimony  in  the  case,  the  reason 
upon  which  it  was  founded;  but  inferences  from  the  facts  as  to  guilt  or 
innocence  of  crime  cannot  be  testified  to.  Nor  can  the  witnesses  be  al- 
lowed to  testify  that  certain  facts  indicate  consciousness,  apprehension, 
truthf Illness,  etc.     (See  People  vs.  Barlrr,  115  X.  Y.  475.) 


DUTIES  AND   BESPOXSflULITIES  OF  MEDICAL   EXI'EIITS.  15 

Again,  anotliei'  rule  observed  in  tlie  courts  on  the  examination  of  ex- 
perts is  that  their  ()])inion  is  to  be  asked,  not  upon  the  ease  as  a  wliole, 
but  upon  hypothetical  (piestions  presented  to  theni.  And  it  is  further 
the  practice  to  allow  each  side  to  call  and  to  pay  expert  witnesses,  and 
to  obtain  their  opinions  upon  the  hypothetical  (juestions  framed  ])y  the 
respective  counsel.  The  theory  on  which  the  experts  are  examined  is 
that  they  are  testifying  to  the  rules  of  a  particular  science  as  applied  to 
a  given  state  of  facts.  Those  rules  are  themselves  facts,  just  as  much  as 
are  the  other  facts  testified  to  by  witnesses  from  their  senses  of  sight  and 
hearing.  Thus  the  laws  of  chemistry  may  be  testified  to  by  a  chenucal 
expert — the  chemical  effects  of  certain  acids,  and  the  results  of  chemical 
analyses,  for  these  are  as  nnich  facts  as  is  the  label  on  a  cei-tain  bottle, 
or  the  name  of  the  apothecary  from  whom  the  bottle  and  its  contents 
were  purchased.  The  primary  object,  therefore,  of  expert  testimony  is, 
not  to  prove  opinions,  but  facts  in  the  shape  of  rides  of  science  or  art 
generally  recognized  by  those  who  are  especially  instructed  in  such  sci- 
ence or  art.  In  certain  domains,  however,  of  science  and  art  it  is  possible 
for  men  of  equal  attainments  to  difi'er  in  their  -views  as  to  the  rules  ap- 
plicable to  a  given  state  of  physical  or  mental  phenomena  presented  to 
them ;  hence  comes  the  sphere  of  what  is  called  "  opinion  evidence." 

The  object  to  be  attained  by  the  courts  is  to  limit  the  opinion  as 
much  as  possible,  and  to  get  as  nearl}^  as  possible  at  the  rules  generally 
recognized  by  the  profession  of  which  the  expert  is  a  member,  and 
thereby  to  keep  the  issue  within  the  realm  of  facts.  This  is  the  theory 
on  which  hypothetical  questions  are  based.  When  an  expert  witness 
has  a  hypothetical  question  put  to  him  and  is  asked  to  give  his  opinion 
upon  the  state  of  facts  presented,  he  is  in  legal  theory  asked  to  state 
what  he  understands  to  be  the  fact  with  regard  to  the  medical  rules 
applicable  to  that  set  of  circumstances. 

In  criminal  cases,  or  cases  de  lunatico  inqu'wendo,  it  is,  of  course,  feasi- 
ble for  the  expert  witnesses  to  personally  examine  and  obsei've  the  party, 
and  they  can  thus  form  an  opinion  as  to  his  mental  condition  at  the  time 
of  such  examination,  which  they  can  express  in  the  shape  of  a  conclusion, 
exijlaining  the  grounds  on  wliich  the  conclusion  is  based.  In  will  con- 
tests, however,  which  form  a  very  large  class  of  the  controversies  in^-olv- 
ing  the  issue  of  mental  competency,  this  is  impossil)le.  In  such  cases 
the  hypothetical  question  is  the  only  recognized  mode  of  eliciting  the  tes- 
timony of  expert  witnesses — i.e.,  a  question  putting  a  supposed  case  based 
upon  the  facts  as  claimed  to  be  established  by  the  other  witnesses,  and 
inquiring  whether  if  such  and  such  were  the  facts  as  to  the  conduct, 
character,  and  history  of  the  deceased  he  would  be  in  the  judgment  of 
the  witness  of  sound  and  disposing  mind  and  memory. 

Many  forcible  ol^jections  are  urged  against  the  use  of  the  In'jiothetical 
cpTestion.  It  is  claimed,  and  with  too  much  truth,  that  this  form  of  ques- 
tion assumes  as  proved  whatever  the  counsel  putting  the  question  has 
endeavored  to  prove,  and  combines  insignificant  witli  inq»ortant  circum- 
stances, and  alleged  facts,  supported  by  slight  and  pci-haps  worthless 
testimony,  with  other  facts  of  which  the  proof  is  strong  and  convinc- 
ing, while  omitting  still  other  facts  of  equal  or  of  greater  importance 
which  may  l)e  overwhelmiugiy  established  upon  the  other  side ;  that  this 
form  of  question  is  in  eifect  nothing  more  nor  less  than  a  summing  up 
by  counsel,  assuming  all  the  allegations  of  fact  in  his  favor  of  which 


IQ  A   SYSTEM   OF  LEGAL  MEDICLNE. 

tliere  may  be  only  a  sciutilla  of  proof,  aud  omitting  all  other  facts,  how- 
ever eleai'ly  established.  Expert  testimony  based  iij)on  such  one-sided 
hy|Dothetical  questions  is  almost  of  necessity  favorable  to  the  questioner, 
and  the  seeming  inconsistency  of  expert  "svitnesses  of  equal  ability  and 
learning  is  veiy  largely  due  to  this  mode  of  examination.  In  other 
words,  expert  witnesses  who  might  agi'ee  if  the  same  hj^jothetical  ques- 
tion were  put  to  them  almost  of  necessity  disagree  when  dii-ectly  op- 
posite h;\i3othetical  questions  are  put  to  them. 

Various  remedies  for  this  evil  have  been  suggested,  such  as  haAdng 
the  hypothetical  questions  fi*amed  by  the  court,  based  on  the  testimony 
of  each  side,  and  asking  the  witness  to  give  his  opinion  on  each  theoiy. 
This  practice,  however,  would  only  partially  obviate  the  difficulty,  unless 
the  court  should,  in  framing  the  question,  assume  to  decide  what  facts 
had  been  estabhslied  on  either  side. 

In  will  cases  there  seems  to  be  no  escape  fi'om  the  necessity  of  hypo- 
thetical questions  in  some  form  so  long  as  the  issue  of  sanity  or  insanity 
is  to  be  decided  by  the  coiu-t  or  the  jury.  It  manifestly  is  impracticable 
to  ask  the  expert  witness  to  give  his  opinion  on  the  whole  case  as  to  whether 
the  deceased  was  sane  or  insane,  for  this  requires  the  expert  to  decide  the 
whole  case,,  and  notliing  remains  for  the  court  or  the  jury  to  do  except, 
perhaps,  to  decide  between  conflicting  exjDert  e^ddence ;  and  this,  of 
coui'se,  is  inconsistent  with  oiu-  whole  theory  of  trial  by  coui"t  or  jury. 
It  might,  jDerhaps,  be  feasible  to  have  the  court  or  the  jiuy  make  find- 
ings of  fact  as  to  the  evidence  of  conduct,  character,  and  history,  and 
then  have  a  commission  of  experts  decide  whether,  on  such  findings,  the 
deceased  was  or  was  not  insane.  This,  however,  is  also  open  to  manifest 
objections,  since  it  would  involve,  in  order  to  be  of  any  value  to  the  ex- 
perts, a  multitude  of  findings  invohdng  minutife  of  conduct  which  would 
be  almost  hopelessly  bewildering  to  a  jury,  aud  in  a  long  trial,  intoler- 
ably biu'densome  to  the  coui't. 

The  true  remedy  for  the  evils  that  undoubtedly  exist  in  the  trial  of 
cases  invohijig  the  question  of  insanity  is  to  have  this  question  sepa- 
rately passed  upon,  as  far  as  practicalile,  b}^  a  commission  of  experts. 
Legislation  in  the  State  of  New  York  has  set  an  example  in  this  direc- 
tion. By  section  658  of  the  Code  of  Crimiual  Procedure  of  the  State  of 
New  York,  it  is  pro\dded  that  when  a  defendant  pleads  insanity  the  court 
may  appoint  a  commission  to  examine  him  and  report  to  the  com't  as  to 
his  sanity  at  the  time  of  the  commission  of  the  crime.  It  is  fiu-ther  pro- 
vided that  if  a  defendant  in  confinement  under  indictment  appears  to  be 
at  any  time  before  or  after  conviction  insane,  the  court  may,  unless  the 
defendant  is  under  sentence  of  death  (in  which  case  powers  are  conferred 
by  other  statutes  upon  the  governor  to  examine  into  the  cpiestion),  ap- 
point a  like  commission  to  examine  him  and  report  to  the  court  as  to  his 
sanity  at  the  time  of  the  examination.  Aud  i£"  the  commission  find  the 
defendant  insane,  the  trial  or  judgment  must  be  suspended  until  he  be- 
comes sane ;  and  the  court,  if  it  deem  his  discharge  dangerous  to  the 
public  peace  or  safety,  must  order  that  he  be  committed  in  the  mean- 
time by  the  sheriff  to  a  State  lunatic  asylum,  aud  that  upon  his  becoming 
sane  he  be  redelivered  hy  the  superintendent  of  the  asylum  to  the  sheriff, 
whereupon  he  must  l;)e  brought  to  trial,  judgment,  or  execution,  as  the 
case  may  be,  or  be  legally  discharged.  (Code  of  Criminal  Procedure, 
sees.  659,  661.) 


DUTIES   AND   IlJ<J.srOA>'SlIiILrril<:S  OF  MEDICAL   EXPERTS.  ]7 

These  i)rovisions  of  tlie  Code  of  Criminal  Procedure,  eiiaet(;d  in  1881, 
supersede  and  (nilart>e  the  previous  provisions  of  the  Laws  of  1874,  (-hap- 
ter  44(5.  That  aet,  for  some  reason  the  propri(;ty  of  wliich  it  is  diflh'ult 
to  understand,  restrieted  its  provisions  to  the  erinies  of  "arson  or  mur- 
der, or  attempt  at  murder,  or  highway  robbery,"  while  the  present  act 
•extends  to  all  crimes. 

There  are  constitutional  difficulties  in  the  way  of  inaking  the  findings 
of  the  commission  conclusive  against  the  accused  in  criminal  cases  if 
they  find  him  sane  at  tlie  time  of  the  alleged  offense,  since  that  would. 
deprive  him  of  his  riglit  to  a  trial  by  .jury  on  that  issue,  which  is  an 
essential  part  of  the  inquiry  as  to  his  guilt. 

It  would  be  well,  however,  if  in  all  civil  cases  in  which  the  issue  of 
sanity  arises  that  qnestion  could  be  submitted  to  a  commission  of  experts. 
In  equity  and  probate  cases  there  is  no  constitutional  right  to  a  trial  by 
jury  in  most  jurisdictions,  and  in  such  cases  this  mode  of  disposing  of 
this  issue  would  seem  to  be  feasible  and  expedient,  and  would  obviate 
many  of  the  objections  now  existing  in  the  trial  of  cases  where  expert 
evidence  as  to  sanity  is  called  for. 

There  are  certain  cases  in  which  expert  evidence  is  frequently  given 
where  it  would  seem  to  be  wholly  inappropriate.  Thus  in  murder  cases 
the  accused  is  very  often  defended  on  the  groniid  of  momentaiy  or  tem- 
porary insanity.  This  defense  really  amounts  to  little  more  than  excus- 
able and  nncontrollable  anger.  It  is  usually  availed  of  in  extreme  cases, 
such  as  where  the  accused  has  killed  the  seducer  of  his  wife.  In  such 
cases  the  jury,  prompted  by  the  feeling  that  the  accused  was  justified  in 
the  killing  by  reason  of  the  injury  received  from  the  deceased,  readUy 
avail  themselves  of  the  excuse  offered  by  the  defense  of  temj^orary  insan- 
ity. Yet  it  is  manifestly  absurd,  in  such  a  case,  to  call  medical  experts 
to  prove  or  disprove  the  proposition  that  a  man  who  is  perfectly  sane 
the  moment  before  the  act  and  perfectly  sane  the  moment  after  can  be 
temporarily  bereft  of  reason  by  rage  and  indignation  so  as  to  be  irre- 
sponsible for  his  acts.  This  is  in  no  proper  sense  a  medical  or  scientific 
question,  but  a  question  of  common  sense  and  common  experience  which 
a  judge  or  a  jury  are  competent  to  decide  for  themselves. 

Much  criticism  has  been  indulged  in  by  the  courts  as  to  the  vjilue  of 
-expert  evidence.  Thus  Lord  Campbell's  remark  in  the  case  of  the  Tracy 
Peerage,  10  CI.  &  Fin.  191,  has  been  often  c[uoted  to  the  effect  that 
''  skilled  witnesses  come  witii  such  a  bias  on  their  minds  to  support  the 
•cause  in  which  they  are  embarked  that  hardly  any  weight  should  be 
given  to  their  evidence."  This  criticism  is  unduly  severe.  There  can 
be  no  doubt  that  the  function  of  expert  witnesses  is  a  most  valuable 
one,  and  is  in  fact  indispensable  to  the  proper  administration  of  justice 
in  the  courts. 

There  is  much  to  be  said  in  favoi-  of  having  certain  persons  selected 
l)y  tlie  Suj^reme  Court  of  the  State  from  the  medical  men  attached  to  the 
State  insane  asylums  and  other  institutions,  and  from  among  those  spe- 
cially skilled  in  questions  of  mental  disease,  to  act  as  experts  whenever 
desired  by  parties  in  the  trial  of  causes^such  experts  to  be  paid  a  cer- 
tain sum  2)er  diem  to  be  fixed  by  law.  The  experts  so  selected  by  the 
court  would  feel  a  degree  of  responsibility  to  the  court,  and  a  degree  of 
freedom  from  obligation  to  the  party  (tailing  them,  w^hich  would  tend  to 
7nake  them  independent  and  impartial. 


18  A   SYSTEM  OF  LEGAL   MEDICINE. 

It  is  needless  to  urge  the  duty  of  medical  experts  to  free  tbemselves- 
as  far  as  possible  fro;:u  the  bias  of  theii'  retainer.  It  should  he  the  aim 
and  pride  of  the  medical  expert  to  realize  that  he  is  after  all  not  a  counsel, 
but  a  witness  called  upon  to  testify  to  facts  of  medical  science  with  which 
he  is  supposed  to  be  familiar,  and  that  those  facts  should  be  testified  to 
fully,  frankly,  and  faii-ly,  just  as  much  as  if  he  were  called  as  a  witness 
to  prove  what  took  place  at  the  time  of  an  alleged  murder.  It  is,  of 
course,  natural  that  pride  of  opinion  should  be  evoked,  and  that  bias 
should  be  aroused,  on  the  part  of  the  medical  expert,  especially  when  sub- 
jected to  harassing  and  sometimes  aunojdng  and  disrespectful  cross-ex- 
amination. The  obligation,  however,  to  tell  the  truth,  the  whole  truth,, 
and  nothing  but  the  truth,  should  be  constantly  before  the  mind  of  the 
medical  expert.  It  is  not  his  function  to  carry  on  a  dialectical  warfare- 
with  opposing  counsel  or  opposing  experts,  but  to  give  a  fuU  and  com- 
plete statement  of'  the  medical  rules  apiDhcable  to  the  case  in  hand,  on 
the  hj-pothetical  questions  put  to  Mm,  without  fear  or  favor. 


INSANITY  IN   ITS  MEDICO-LEGAL   BEARINOS. 

BY 

allan  mrlaxe  hamilton,  m.d. 

Part  L — General  Introduction. 

Mind  is  that  niaiiifestatiou  of  life  which  depends  upon  the  functional 
activity  of  the  brain,  and  is  expressed  in  the  exercise  of  feeling,  thought, 
and  volition.  In  the  light  of  modern  psychological  research  I  do  not 
believe  it  can  be  regarded  as  a  distinct  entity,  as  it  has  been  for  so  long 
a  time,  and  is  to-day,  by  some  metaphysicians  and  many  theologians.  It 
is  my  purpose  to  Ijriefly  consider  normal  and  diseased  function  alone, 
referring  my  i-eaders  to  the  accumulated  researches  of  a  host  of  psychi- 
atrists, physiologists,  and  anatomists  for  extended  data. 

The  human  being  possesses  an  ego  which  is  the  basis  of  all  mental 
activity,  and  through  it  he  realizes  the  relations  he  l)ears  to  the  external 
world,  as  well  as  the  value  of  impressions  which  have  been  transformed 
into  concepts,  while  previous  experiences  are  stored  up  and  form  the 
basis  of  thought  and  action.  The  outer  world  Ijears  an  indirect  relation 
toward  him  through  external  experience.  All  of  his  ability  for  weighing, 
coordinating,  and  using  his  own  internal  formidated  impressions  (con- 
cepts), as  well  as  of  putting  himself  in  every  way  in  proper  touch  with 
outside  things,  depends  upon  the  faculty  of  attention  (apperception). 
The  power  of  attention  and  its  connection  with  concept  selection  deter- 
mines greatly  the  intricacy  and  degree  of  tliouglit  and  action. 

The  many  steps  of  mental  development  have  1)een  ti-aced  h\  pains- 
taking ol)servers  whose  results  are  incontrovei'til^le,  and  in  tliese  days  of 
progress  we  are  furnished  witli  indisputable  facts  wliich  show  bow  the 
mind  may  be  partially  or  generally  destroyed  in  a  distinctly  definite  man- 
ner by  morbid  processes  and  focal  disease.  Extirpation  of  certain  tracts 
or  regions  is  followed  by  perversion  or  abolition,  it  being  possibh*  to  repeat 
such  experiments  over  and  over  again  if  one  chooses.  We  have  l)een 
shown  that  ancephalous  monsters  exist,  and  modern  localization  has 
thoroughly  changed  our  inexact  and  speculative  knowledge  of  lu-ain 
function,  Avhich  a  quarter  of  a  century  ago  ])artook  largely  of  the  nature 
of  guess-work.  It  is,  moreover,  possil)le,  after  studying  the  questions  of 
heredity  and  environment,  to  realize  the  influences  that  materially  act  in 
the  genesis  of  mental  development  or  decay.  The  healthy  play  of  hu- 
man passions  and  feelings  depends  upon  cerebral  integiity,  and  possibly 
before  long  our  knowledge  and  appreciation  of  the  origin  of  many  of  the 

in 


20  A   SYSTEM  OF  LEGAL   MEDICINE. 

higher  attributes  of  mental  f imctiou  -v^ill  have  a  material  and  satisfaetoiy 
explanation.  For  the  proper  study  of  the  mind  in  health  and  disease  we 
must  \dew  the  subject  fii-st  from  the  side  of  deA^elopment  and  degenera- 
tion, and,  again,  we  must  consider  the  coordination  and  mutual  depend- 
ence of  cellular  functional  activity  and  efferent  and  aiferent  perfectness 
of  communication.  It  is  better  to  break  away  from  the  ii-on-clad  so-called 
divisions  of  mind  adopted  by  the  older  metaphysicians  and  to  consider  the 
manifestations  of  brain  action  as  not  only  extremely  variable  but  com- 
plex in  their  display.  After  all,  the  power  and  extent  of  mental  action 
depend  upon  the  capacity  of  the  apparatus  which  gives  bii'th  to  psychic 
activity.  With  the  more  primitive  nervous  organs  we  have  nothing  here 
to  do,  but  the  study  of  the  mind  of  man  is  before  us,  and  we  shall  proceed 
to  the  discussion  of  its  impairment. 

It  may  be  assumed  beyond  doubt  that  the  growth  of  mteJIigence 
tears  relation  to  the  complexHij  of  the  nervous  organization  or  the  evolu- 
tion of  the  higher  ganglia.  It  would  be  difficult  to  form  any  exact  esti- 
mate of  its  extent,  and  the  j)oint  to  which  it  may  be  developed  even  in 
the  lower  animals,  but  it  may  be  assumed  that  convolutionary  perfection, 
completeness  in  the  connection  of  cells  and  groups  of  cells,  determines 
the  possibilities  of  mental  growth.  There  is  no  absolute  indication  of 
intellectual  power  to  be  derived  fi'om  the  size  of  the  brain  or  the  shape 
of  the  head  alone,  except  in  a  most  general  way.  Students  of  craniology 
have  called  attention  to  the  asymmetry  of  the  cranium  and  the  irregu- 
larity and  exaggeration  of  the  fissiu-es  which  divide  the  cerebral  convo- 
lutions, but  anything  more  than  this  is  mere  guess-work.  Abundant 
statistics  are  on  record  to  i3rove  that  the  heaviest  brains  do  not  go  with 
\h.Q  grandest  intellects,  but,  on  tlie  contrary,  these  statistics  indubitably 
show  that  some  of  the  gi'eatest  minds  are  the  product  of  insignificant 
brains  so  far  as  mere  weight  is  concerned.  We  are  safe,  however,  in 
fixing  the  minimum  weight  of  the  normal  brain,  and  assuming  that  cer- 
tain figures  must  be  associated  with  a  very  low  degree  of  intelligence, 
or  none  at  aU.  Gratiolet  {The  Brain  as  an  Organ  of  Mind,  Bastian,  p.  36) 
has  fixed  the  lowest  limit  compatible  ^^dth.  ordinary  intelligence  at  900 
drams ;  Broca  at  907  for  the  female  and  1049  for  the  male.  The  aver- 
age weight  of  the  human  brain  has  been  estimated  by  Shaipey  as  fol- 
lows :  maximum  weight  of  adult  male  brain,  65  oz. ;  average  weight  of 
adult  male  brain,  49J  oz. ;  minimum  weight  of  adult  male  brain,  34  oz. ; 
maximum  weight  of  adult  female  brain,  56  oz. ;  average  weight  of  adult 
female  brain,  44  oz. ;  minhnum  weight  of  adult  female  brain,  31  oz.  Mor- 
ris has  re])()rted  the  hea^'iest  brain  so  far  recorded,  the  weight  being  67 
oz.  [Brit.  Med.  Jour.,  October  6,  1872).  After  all,  the  true  test  of  intelli- 
gence is  that  of  general  structui-al  development,  and  it  is  i;»robable 
that,  if  the  microscope  could  be  brought  to  reveal  the  most  delicate 
commissural  connections,  tlie  brain  nearest  perfection  would  show  a 
well-d(n-eloped  convolutionary  surface,  jjlentifnlly  supplied  with  corti- 
cal cells,  and  with  intricate  communications  between  separate  groups. 
The  brains  of  persons  of  low  intelligence — idiots  and  others — on  the  con- 
trary, slu)w  a  flatness  of  the  external  surface,  Avith  imperfectly  defined 
and  se])arated  convolutions,  a  notable  degree  of  flatness  of  these,  as  well 
as  asymmetry  or  a  distinct  difference  between  the  two  hemispheres.  At 
another  part  of  this  article  these  matters  will  be  considered  in  extenso. 

The  lessons  of  physiology  and  pathology  throw  much  light  upon  the 


JXSJXlTY  JX  ITS  MEDICO-LEGAL   BEARINGS. 


21 


functions  of  the  brain  and  changes  in  the  genesis  of  mental  expression 
that  follow  its  partial  removal  or  impairment  by  disease.  An  experiment 
often  performed  iu  the  pli^'siologieal  lal)oratory  consists  in  the  removal  of 
the  cerebrum  from  pigeons  and  frogs,  resulting  in  the  deprivation  of  all 
mental  control  and  the  persistence  onl}'^  of  reflex  function  <nid  an  autom- 
atism whi(;h  follows  stimulation  or  suggestion  and  is  shown  in  peculiar 
motor  activity  of  one  kind.  Birds  thrown  in  the  air  for  a  time  fly,  and 
swallow  food  only  when  it  is  ])la(;ed  so  that  the  muscles  of  the  throat  are 
thus  stimidated  to  reflex  action,  there  being  nothing  volitional.  The 
frog,  if  mutilated  in  this  wa}',  will  only  jump  if  pricked,  and  though  when 
placed  upon  an  inclined  l)ortrd  it  finds  its  way  to  the  top,  it  is  simply  tlie 
result  of  a  species  of  automatism  which  has  no  immediate  intellectual 
connection,  Init  is  something  acquired  that  has  become  habit. 

The  tolerance  of  the  hvain  to  injurjj  is  i-emarkable,  for  it  may  undergo 
very  decided  mutilation,  even  losing  much  of  its  substance,  often  with- 
out any  considerable  residtant  imi^airment  of  function,  and  sometimes 
none  whatever.  Modern  surgery  has  proved  that  aU  sorts  of  operative 
procedures,  which  until  recently  were  supposed  to  have  no  other  results 
than  those  of  a  fatal  character,  are  now  not  only  proper  and  remedial 
measures,  but  that  the  surgeon's  knife  can  enter  the  brain  in  many 
places  without  au}^  risk  whatever  to  life.  Hernia  cerebri  of  magnitude 
often  follows  comminuted  frontal  fracture  with  loss  of  bone,  and  removal 
or  necrosis  of  the  cerebral  tissue  does 
not  always  mean  any  great  impairment 
or  abolition  of  mental  function.  The 
celebrated  New  England  tamping-iron 
case  is  familiar  to  many  people.  The 
suliject  was  a  workinan  who  was  en- 
gaged in  drilling  a  hole  in  the  rock. 
Through  a  premature  explosion  the 
blast  went  oif,  ])lowing  the  tamping- 
iron,  which  was  several  feet  long  and 
at  least  one  inch  in  diameter,  through 
the  anterior  part  of  the  head,  it  enter- 
ing below  and  passing  out  above,  cre- 
ating an  opening  of  such  size  that 
much  of  the  fore-brain  was  destroyed. 
(Fig.  1.)  The  immediate  effects  were, 
considering  the  serious  shock  and  loss 
of  substance,  comparatively  insignif- 
icant, and  he  lived  for  many  3'ears, 
eventually  dying  of  tuberculosis.  Ex- 
cept for  an  irritability  of  temper  there 
was  little  mental  weakness.  Large 
tumors  which  nuiy  occupy  the  greater 

part  of  one  hemisphere  may  exist  for  years,  giving  no  indication  of  their 
presence ;  bony  excrescences  or  spicula^  may  also  make  what  nuist  be 
considered  dangerous  pressure,  and  still  the  sites  involved  seem  to  be 
those  without  function,  or  at  least  tolerate  the  unusiial  violence. 

On  the  other  hand,  a  very  small  lesion  may  create  great  miseliief. 
This  is  especially  true  when  it  is  situated  at  the  lower  and  posterior  part 
of  the  brain,  where  nerve  trunks  and  imjiortant  nuclear  centers  exist. 


Fig.  1. 


2% 


■A   SYSTEM  OF  LEGAL  MEDLCINE. 


Fig.  3. 


Fig.  3. 


Fig.  4. 


i     Diagrams  illustrating  the  ramifications  of  fibers  and  the  location  of  the  basal  sensory  area  of 
^  the  brain.     (Testut  and  Meynert.) 


Fig.  3.— Intracerebral  fibers:  a,  anterior  extremity  of  left  hemisphere;  if),  its  posterior  ex- 
tremity; c,  fissure  of  Sylvius;  d,  temporal  lobe;  e,  splenius;  1,  longitudinal  fibers  of  the  cingu- 
lum ;  8,  long  superior  fasciculus  (fasciculus  arcuatus) ;  3,  inferior  longitudinal  fibers ;  4,  unciform 
fibers;  5,  5,  arched  fibers. 

Fig.  3.— Diagram  of  arched  fibers  and  those  with  close  local  connections:  1,  short  arched 
fibers  going  from  one  convohition  to  a  neighboring  one ;  3,  long  arched  fibers  going  from  one 
convolution  to  a  more  distant  one. 

Fig.  4.— Diagram  representing  a  vertico-lateral  section  of  the  left  hemisphere,  showing  the 
sensory  fibers  and  their  irradiation  toward  tlie  cortex:  1,  optic  thalamus;  a,  geniculate  bodies; 
3,  posterior  extremity  of  hemispliere;  4,  fissure  of  Rolando;  5,  ascending  frontal  convolution ; 
0,  ascending  parietal  convolution;  7,  pyramidal  (red),  going  to  the  motor  zone;  8,  sensory  fibers 
(blue);  9,  optic  fibers;  10,  sensory  decussation;  11,  vertical  sensory  fibers  going  to  motor  zone; 
13,  horizontal  sensory  fibers  going  to  the  parietal,  temporal,  and  occinital  lobea- 


IXSANITY  IX  ITS  MEDICO-LEGAL  BEABINGS. 


23 


Here  we  find  the  origin  of  tlie  cranial  nerves,  which  play  so  important 
a  part  in  si^ecial  sensation,  in  respiration,  the  action  of  the  heart,  and 
digestion.  Lesions  at  certain  parts  of  the  brain  concerned  in  conduction, 
may  wholly  or  partially  involve  the  great  l:»iindle  of  nerve-filiers  which 
descend  or  ascend,  producing  paralysis  of  sensation  or  motion,  cutting 
off  the  centripetal  impression  or  the  centrifugal  volitional  flow.     Above 


Fig.  5. 

Diagram  representing  the  course  of  the  pyramidal  fibers  between  the  cerebral  cortex  and  the 
cord  and  anterior  nerve  roots.     (Testut.) 


A,  Pyramidal  fasciculus  on  the  right  side  (yellow) ;  B,  pyramidal  fasciculus  on  the  left  side 
(red);  a,  a',  direct  and  crossed  pyramidal  fibers  of  the  risht  side;  b,  /)',  direct  and  crossed 
pyramidal  fibers  of  the  left  side;  1,  motor  zone  of  the  cortex;  2,  internal  capsule;  3,  decussa- 
tion of  pyramids  corresponding  to  the  transverse  axis  X,  X;  4,  trunlc  of  cervical  cord  seen 
anterioriy;  5,  inferior  part  of  tlie  dorsal  cord;  6,  6,  anterior  nerve  roots  of  the  right  side; 
15',  6',  anterior  nerve  roots  of  the  left  side.  "  It  is  seen  in  tliis  diagram  that  one  side  corresponds 
to  the  other :  first,  the  crossed  pyi-amidal  fibers  entirelv  passing  over  to  the  other  side  at  the  root 
of  decussation  of  the  pyramids:  second,  the  direct  pvraiuidal  fillers  are  crossed,  bundle  by  bun- 
dle, throughout  the  length  of  tlie  cord:  in  short,  all  the  motor  fibers  issuing  from  one  hemi- 
sphere, tliat  follow  the  course  of  crossed  or  dix'ect  fasciculi,  emerge  from  the  cord  as  anterior 
nerve  roots  on  the  opposite  side. " 


24 


A   SYSTEM   OF  LEGAL   MEDLCLNE. 


Diagram,  representing  the  topography  of  the  cortical  areas  of  the  left  hemisphere. 
(The  method  of  division  is  that  of  Pitres.) 


(Testut.) 


a,  a,  Prefrontal  section;  7),  Z>,  pediculo-frontal  section ;  c,  c,  frontal  section;  d,  d,  parietal 
section;  e,  c,  pedicnlo-parietal ;  /, /,  occipital  section.  The  uioZet  tinting  indicates  the  psychic 
zone;  bhtc,  the  ,sf /(.■^ory ;  red,  the  motor;  green,  the  geniculate  centers  (of  face,  and  nerves  con- 
cerned in  mastication  as  well  as  the  hypoglossal) ;  yellow,  the  center  of  apliasia.  I,  Agraphia 
center;  J7,  aphasic  center;  JIJ,  center  of  lovi^er  extremity ;  Jl^  of  superior  extremity;  F,  motor 
center  of  face ;  VI,  center  of  word-blindness ;  VII,  center  of  liemianopsia ;  VIII,  center  of 
word-deafness.  Besides  these  there  is  a  center  in  the  unciate  gyrus,  which  probably  controls 
the  sense  of  smell. 


INSAXITl'  IX  I'L'i  MEDICO-LEGAL  BEARINGS. 


25 


Fig.  8. 


--h 


Fig-.  9. 


Fig.  10. 


Sections  of  the  cerebrum  showing  the  association  fiber  system.    (Testut.) 

Figs.  7  and  8.— Pediciilo-f rental  section :  1, 2,  3,  first,  second,  and  third  frontal  convolutions; 
4,  island  of  Reil;   5,  orbital  convolutions;   6,   anterior  extremity  of  temporal  convolutions; 

7,  convolutions  of  corpus  callosum;  8.  superior  pediculo-frontal  fibers;  i'.  middle  pediculo- 
frontal  fibers;  10,  inferior  pediculo-frontal  fibers;  11,  orbital  fibers;  VZ.  corpus  callosum:  13,  cau- 
date nucleus;  14,  internal  capsule;  15,  lenticular  nucleus;  7,  agraphic  center;  77,  aphasic  center 
(see  Mill's  article);  A,  A,  psychic  fibers  (violet);  7?,  aphasic  fibers  (yellow);  C,  sensory  fibers 
(blue). 

Figs.  9  and  10.— Frontal  section  of  cerebrum:  1,  ascending  frontal  convolution;  2,  foot  of 
ascending  parietal  convolution;  ;i,  island  of  Reil:  4,  4',  4",  first,  second,  and  third  temporal 
convolutions;  .5,  superior  frontal  fibers:  (i,  middle  frontal  fibers;  7,  inferior  frontal  fibers; 

8,  sphenoidal  fibers:  9,  cm-pus  callosum;  10,  caudate  nucleus;  11,  optic  thalamus;  12,  internal 
capsule:  13,  lenticular  nucleus:  14,  external  capsule:  1.5,  claustrum;  777,  motor  center  for  in- 
ferior extreiuity ;  71',  motor  center  for  superior  extremity ;  V,  motor  center  for  face ;  D,  D,  mo- 
tor fibers  (red);  E,  sensory  (blue);  C,  geniculate  fibers  (green). 


26 


A  SYSTEM  OF  LEGAL  MEDICINE. 


^-i-r-rrn-S^f-fflffiEfpRht^      fj,     ^..-T^'-T'^r^'xrr,.,^, 


Fig.  11. 
Showing  the  arterial  supply  at  the  base  of  the  brain.     (Testut.) 


1,  Internal  carotid  artery,  divided  at  the  opening  of  the  cavernous  sinus ;  2,  anterior  cere- 
bral artery:  3,  middle  cerebral  artery  and  Sylvian  artery;  4.  choroid  artery;  .5,  anterioi' com- 
municating artery;  6.  posterior  communicating  artery;  7,  posterior  cerebral  artery,  with  (70  its 
anterior.  (7")  its  middle,  and  (7'")  its  posterior  branches;  8,  basilar  artery;  9,  superior  cerebel- 
lar artery;  10,  inferior  and  anterior  cerebellar  arteries;  11,  bulbar  arteries;  12,  vertebral  arte- 
ries; 13,  inferior  and  posterior  cerebellar  arteries;  14,  anterior  spinal  artery;  a,  anterior  ex- 
tremity of  inter-hemispherical  fissure;  ti,  its  posterior  extremity;  c,  olfactive  bulbs;  d,  optic 
commissure;  e,  pons; /,  bulb;  y,  cerebellum.  The  left  hemisphere  of  cerebellxim  and  right 
temporo-sphenoidal  lobe  have  been  removed. 


INSANITY  IN  ITS  MEDICO-LEGAL   BEAlUXdS.  27 

and  in  the  cortex  or  investing-  gray  matter  we  find  the  seat  of  that  form 
of  nervons  action  which  is  tlie  direct  output  of  celluhir  functic^n.  In 
some  phxces  are  well-determined  areas  wliose  special  office  is  to  originate 
definite  motor  impulses.  Thanks  to  Hitzig-,  Fritsch,  Ferrier,  and  a  host 
of  other  observers,  we  know  that  localized  irritation  of  these  will  be  fol- 
lowed by  muscular  contractions  in  distal  parts,  and.  that  these  are  of  a 
uniform  character,  as  can  be  repeatedly  proved.  We  know  that  poste- 
riorly in  the  oc(npital  lobes  are  located  centers  for  vision ;  that  above  in 
the  parietal  region  is  what  is  known  as  the  angular  gijrus,  a  center  for 
the  coordination  of  symbols  that  play  a  part  in  audition  ;  that  anteriorly 
on  the  left  side  of  the  brain,  at  the  foot  of  the  third  frontal  convolution, 
is  a  center  for  speech,  and  that  when  destroyed  the  condition  known  as 
aphasia  is  a  result ;  that  at  the  base  of  the  brain  anteriorly  is  a  center 
for  smell.  These,  as  well  as  many  others,  have  been  located  by  experi- 
ment and  proved  to  exist  by  the  results  of  disease. 

What  the  exact  location  of  the  apparatus  of  vtind  is  has  always  been 
a  matter  of  active  dispute,  although  the  great  mass  of  testimony  goes  to 
show  that  it  is  the  fore-])raiu  which  is  concerned.  In  the  light  of  exjjeri- 
ment  and  clinical  observation  this  theory  seems  open  to  some  question, 
and  the  views  of  Hugiilings- Jackson  and  Exner  are  less  conservative 
and  more  i-easonable.  I  am  therefore  inclined  to  agree  with  them  that 
no  one  part  of  the  gray  matter  is  alone  concerned,  but  rather  that  mental 
action  is  the  result  of  general  and  complex  function.  Figs.  2,  3,  4,  5,  6, 
7,  8,  9,  and  10,  from  Testut's  admirable  treatise  {Traite  d'Anafomie  Hu- 
maine,  etc.,  t.  2,  Paris,  1S93),  will  enable  the  reader  to  more  readily  recog- 
nize the  intricate  system  of  communicatory  or  associative  fibers  in  the 
brain  itself,  as  well  as  those  which  pass  eentrif ugally.  The  sensory  organs 
and  tracts  that  are  engaged  in  the  production  of  mind  are  extensive  and 
intricate,  and  not  only  connect  the  concept,  propositionizing,  auditory, 
visual,  and  other  sensory  and  motor  centers  which  may  be  almost  adjacent, 
but  those  as  well  which  are  more  remote,  and  others  form  important  tracts 
which  are  direct  or  commissural.  Figs.  2,  3,  4,  5,  diagrammaticaUy  illus- 
trate the  course  of  these  fibers.  Figs.  6,  7,  8,  9,  10,  indicate  the  general 
connection  of  these  with  jjarts  of  the  brain  in  which  special  functions  are 
located ;  Fig.  6  showing  the  entire  lateral  cortical  surface  of  one  hemi- 
sphere, with  its  function-zones  mapped  out  and  either  represented  in 
color  or  by  limitmg  lines,  and  Figs.  7,  8,  9,  and  ]  0,  the  association  systems 
of  the  fore-brain.  Fig.  11  shows  the  important  basal  ni-terial  circulation 
of  the  brain,  which  is  often  subject  to  oltstructive  changes  or  other  dis- 
ease, especially  in  those  forms  of  dementia  consecutive  to  thrombosis, 
embohsm,  or  rupture  from  any  other  cause,  the  left  middle  cerebral  artery 
being  that  most  often  involved. 

Kirchhoff  {Handhooh  of  Insanifi/,  p.  9)  formulates  the  status  of  knowl- 
edge of  localization  regarding  the  deductions  to  be  drawn  from  disease  or 
non-development  of  the  brain.     He  calls  attention  to  the  fact  that : 

1.  "The  interruption  of  certain  systems  of  fibers  leading  from  the 
cerebrum  to  the  cerebellmn  gives  rise  to  distinct  slowness  and  difficulty 
of  the  mental  functions. 

2.  "  The  optic  thalamus  seems  to  possess  more  intimate  relation  to 
the  higher  mental  functions  than  does  the  corpus  striatum,  inasmuch  as 
the  former  alone  undergoes  atrophy  in  congenital  absence  of  the  cerebral 
hemisphereso 


28  ^   SYSTE^I  OF  LEGAL  MEDtCISE. 

3.  "  The  disturbance  in  the  intellectual  development  of  individuals  in 
whom  the  corpus  callosum  is  absent  is  very  small,  indicating  that  the 
higher  mental  processes  are  not  dependent  upon  the  frontal  brain  alone  : 
indeed,  in  these  cases  the  occipital  lobes  are  mainly  atroijlded. 

4.  "  If  the  brain  is  imj^erfectly  develojDcd  as  a  whole,  as  in  some  idiots, 
there  can  be  no  question  of  localization,  nor  is  any  fui-ther  conclusion 
warranted  from  irregular  development  in  the  cortical  layers,  unless  it  is 
cu'cumscribed." 

In  illustration  of  this  he  alludes  to  the  discovery  of  only  narrow  py- 
ramidal cells  in  the  frontal  lobes  of  a  few  idiots,  which  were  so  irregularly 
distributed  that  it  was  ahnost  imjiossible  to  distinguish  the  layers.  Here 
the  imperfect  mental  de^^elopment  may  be  attributed  to  the  imperfect 
development  of  the  frontal  cortex. 

There  appear  to  be  no  means  of  determining  the  seat  of  memory, 
but  judging  from  the  complex  processes  which  operate  in  the  formation 
of  concepts,  as  weU  as  their  diverse  nature,  it  is  probable  that  they  are 
stored  up  in  no  particular  locality ;  in  fact,  the  pathologj^  of  dementia 
and  its  morbid  anatomj'  presume  a  jDrogTessive  and  general  destructive 
change. 

MENTAL  ELEMENTS — ^NORj\LyL,   AND   DISEASED. 

Au}^  extended  consideration  of  physiological  psychology  in  a  book  of 
this  kind  would  be  out  of  place,  but  it  will  suffice  to  state  that  the  di\ds- 
ions  of  mind  are  three  in  number:  feeling,  which  includes  sensibOity 
and  emotion ;  thhdung,  which  inij^lies  intellection  or  thought ;  and  volition, 
which  is  a  result  of  the  exercise  of  the  fh'st  two.  These  may  be  still  fui-- 
ther  amplified  and  subdivided.  In  the  older  definitions  of  mind  it  was 
the  custom  to  speak  of  judgment,  reason,  and  memoiy.  but,  after  all.  these 
may  be  better  included  under  the  head  of  "  thinking.'' 

In  the  study  of  the  normal  as  weU  as  of  the  diseased  mind  we  are  to 
consider  perception,  which  implies  the  recognition  and  appreciation  of 
the  relations  of  sensation  and  the  agencies  which  aff'ect  the  same.  This 
means  the  recognition  of  the  part  played  by  the  organs  of  special  sense 
— the  afferent  nerves  of  conduction,  the  existence  of  groups  of  cells  or 
nerve  centers  which  receive  the  impressions  from  without,  and  the  more 
imj^ortant  condition  of  consciousness.  The  kind  of  intelligence  which  is 
necessary  for  the  mensuration  of  the  form  and  physical  attriljutes  of 
objects  must  be  taken  into  account,  especially  when  we  come  to  consider 
the  formation  of  hallucinations  and  iUusioiis.  T\"lien  a  perception  has 
been  recognized  and  remembered,  it  becomes  a  concept  or  idea :  and  when 
comparison  is  made  and  the  process  of  reasoning  takes  place,  di  judgment 
is  arrived  at. 

One  of  the  most  important  mental  faculties  is  that  of  memory,  which 
enables  the  individual  to  retain  and  store  up  impressions,  and  which 
really  forms  the  basis  of  the  most  important  forms  of  higher  mental  ac- 
ti\dty.  Memoiy  may  be  said  to  be  of  two  kinds — that  which  consists  in 
the  retention  of  perceptions  or  external  impressions,  and  tliat  which  con- 
cerns the  acknowledged  recognition  of  self  and  the  inner  condition  (or- 
ganic memory).  Sensations  of  a  personal  kind  are  recognized  and  re- 
membered, and  form  the  basis  of  self-api^reciation.  Tliis  latter  form  of 
memory,  when  affected,  results  in  the  change  of  the  ego  which  is  so 


ixsAXiry  IX  its  mijdico-ijjcjl  niiAniXiin.  29 

niarked  in  some  lialluciiiatoiy  insanities.  The  ^Toupin*^  of  eoneeijts  or 
ideas,  and  their  association,  constitutes  reasonin*^  and  judgment,  and 
precedes  volition,  which  may  be  tlie  demonstrative  active  expression  of 
their  conclusion.  The  degree  of  this  manifestati(jn  of  course  varies  Ncrv 
much  with  the  complexity  and  the  extent  of  the  nu-ntal  operations  wiiich 
are  behind  it;  and  it  differs  from  reflex  action  in  tlu;  fact  that  the  actixe 
demonstration  is  iiot  governed  by  thought  in  the  latter,  l)ut  is  the  result 
of  a  lively  exteriial  impression,  which  is  si)inal  in  character,  and  the 
motor  ex])ression  uuiy  or  may  not  l)e  attended  by  unconscious,  cere- 
bration. 

The  simplest  f(jrm  of  retlex  action  nui}'  be  illustrated  1)y  the  rapid 
withdrawal  of  the  finger  from  a  hot  surface,  which  produces  actual  phys- 
ical pain,  the  cause  or  degree  of  which  is  not  weighed  or  estimated  Ijy 
the  mind,  and  the  act  itself  is  also  too  rapid  to  be  a  volitional  one.  Then, 
again,  there  are  so-called  instinctive  reflex  acts,  where  previous  associa- 
tions and  experiences  enter  into  the  causation  of  particular  muscular 
contraction,  and  Avliere  no  apparent  cons(;i(ms  appreciation  exists.  The 
importance  of  the  volitional  act  is,  of  course,  gauged  largel}'  by  the  i)ar- 
ticjpation  of  reason  and  judgment,  as  well  as  the  concurrence  of  affectiA'e 
feeling ;  and  we  are  presented  in  health  and  disease  with  numy  gradations 
in  the  acts  of  will  wliich  begin  as  impulses  and  reach  the  dignity  of  elab- 
orate exercise  of  force  after  comparison,  judgment,  and  discrimination 
have  been  operating.  The  capacity  for  inhil)ition,  and,  on  the  other 
hand,  the  influence  of  emotion  and  the  absence  of  self-control,  are  to  be 
considered. 

In  the  study  of  those  conditions  which  suggest  mental  disease  we  are, 
of  course,  to  ascertain,  if  possible,  not  only  the  previous  life  of  the  indi- 
vidual, but  his  environment  and  such  causes  as  may  have  resulted  in  the 
mental  degeneration.  We  are  also  to  compare  his  mental  expressions 
and  conduct  with  that  of  others  in  the  comnumity  in  which  he  may  be 
livdng,  to  consider  his  training  and  education,  and  to  go  back,  if  possible, 
into  the  remote  past,  to  discover  what  influence,  if  any,  has  been  exerted 
upon  his  development  as  a  result  of  the  willful  faults  or  involuntary  mis- 
fortunes of  his  progenitors.  Mental  disease  is  not,  as  a  rule,  of  sudden 
origin.  There  is  nearly  always  some  predisposition  or  some  long-existing: 
cause,  and  in  a  very  great  many  cases  the  process  of  mental  dissoluti(.»n 
is  a  slow  one  and  the  departure  from  mental  health  is  prolonged.  This 
should  be  borne  in  mind,  especially  in  the  consideration  of  cases  Avhich 
f(n-m  the  subject  of  legal  inquiry ;  but  the  poiwlar  idea  of  insanity  inipUes 
all  sorts  of  possibilities  and  improbabilities  which  do  not  stand  the  test 
of  clinical  experience. 


Special  Indications  of  Mental  Weakness. 

Among  the  important  evidences  of  mental  deterioration  ai*e  Halluci- 
nations; Illusions  and  Delusions;  Insistent  and  Imperative  Concepts; 
Loss  of  Memory  (both  external  and  organic);  Inharmonious  Exercise  of 
Ideation  or  Keasoning  Power;  Emotional  Disturbance  and  Volitional 
Diminution  or  Exaggeration ;  Physical  Changes. 


30  ^   SYSTEM  OF  LEGAL  MEDICIXE. 


HALLUCIXATIOXS. 


An  hallucination  is  a  false  perception,  and  in  this  respect  differs 
from  an  illusion,  by  reason  of  the  fact  that  the  error  leading  to  the  crea- 
tion of  the  latter  consists  in  the  distortion  of  an  objective  thing.  Hallu- 
cinations are  of  three  kinds  : 

First.  Those  due  to  a  defect  of  the  peripheral  perceptive  organ,  or  of 
the  afferent  nerves  and  centripetal  fibers. 

Second.  The  form  "o^hich  includes  examples  of  distui'bance  of  certain 
centi'al  organs. 

Third.  TMiere  the  disorder  is  chiefly  confined  to  limited  cortical  areas. 

It  has  been  held  by  some  authors  that  it  is  possil)le  to  have  hallucina- 
tions Trithout  any  cerebral  partici2:)ation,  or,  in  other  words,  any  mental 
abeiTation,  the  organs  of  special  sense  themselves  possessing  a  certain 
local  memorj'.  This  seems  to  me  to  be  a  meretricious  distinction  and 
one  "vrhoUy  speculative,  for  the  reason  that  it  is  impossible  to  have  an 
hallucination  without  a  previously  formed  concept,  no  matter  how  an- 
cient. Persons  who  become  blind  after  a  time  may  have  visual  halluci- 
nations, but  those  congenitally  blind  can,  of  course,  have  nothing  of  the 
kind,  as  no  image  has  ever  been  projected  upon  the  sensorium. 

It  is  important  to  consider  hallucinations  with  regard  to  their  pathog- 
eny :  first,  in  connection  with  the  organs  of  special  sense  themselves ; 
and  second,  where  they  are  centrally  originated,  as  a  result  of  an  irrita- 
tion and  stimulus  of  certain  Ijrain  tracts  where  concej)ts  have  been  stored 
lip. 

The  simplest  form  of  hallucination  is  that  due  to  some  local  imtation 
or  disease  of  one  of  the  perceptive  organs,  and  the  false  images  need 
not  necessarily  be  insane ;  in  fact,  a  variety  of  spiuious  sensory  images, 
without  ol)jective  basis,  may  be  recognized  by  the  individual  as  the  re- 
sidt  of  disease  or  temporary  disturbances  of  the  cerebral  circulation,  he 
being  a1>le  to  ajjpreciate  their  source,  and  it  is  only  when  the  higher 
powers  of  the  mind  are  so  diseased  that  comparison  and  judgment  fail 
to  act  as  correctives,  that  the  mental  integrity  of  the  individual  is  ques- 
tioned. All  \'arieties  of  sensory-  impression  are  likely  to  be  perverted  by 
causes  which  it  is  not  necessar}'  to  mention  here,  except  in  a  general 
way ;  but  we  may  consider  the  numerou;^  factors  that  may  pervert  the 
innervation  of  the  important  organs  which  serve  to  keep  us  in  relation 
Avith  the  outsi  ^■  world.  It  is  not  difficult  to  explain  by  purely  jjliysi- 
cal  agencies  njiiny  startling  varieties  of  disturbed  special  sensation. 

Hallufinations  are  divided  into  visual,  auditory,  olfactirc,  and  ciitaneous. 

Visual  hallucinations  are  largely  dependent  upon  retinal  phenom- 
ena, and  are  often  connected  with  ischemia  or  disturbed  circulation  at 
the  back  of  the  eye.  Tlje  pulsation  of  the  central  arter\'  or  variations  in 
the  retinal  light  may  give  rise  to  rings  or  disks  of  light,  dark  spots, 
flashes,  stars,  or  other  scintilla,  which  may  or  not  be  used  by  a  dis- 
eased brain  as  a  basis  for  an  elal)orate  morbid  concept  association. 

Wliat  other  exjiansion  there  is  of  the  mechanism  which  results  in  the 
misintcritretation  of  siin])le  distal  variations,  I  am  unable  to  say.  It 
would  ajtpear,  however,  that  a  vei-y  indift'erent  form  of  peripheral  stimu- 
lation will  often  start  a  train  of  disorderly  thought  at  a  time  when  in- 
hibition is  not  exerted.     During  the  condition  of  sleep,  when  the  upper 


IXSANITY  JX  ITS   MKDirO-LKC.AL    UKAUIXCS.  31 

■cortieal  layers  are  inactive,  the  mere  flasliinjj^  of  a  light  before  the  ej-es 
of  the  sleeper  is  likely  to  produce  complex  dreams  of  fire  and  an  unsys- 
tematized c(nuparison  of  concepts  of  some  intricacy. 

There  are  some  rules  which  govern  the  occurrence  of  peri})h('ral  visual 
hallucinations,  aiul  one  is  that  they  are  more  pronounced  when  the  eyes 
.are  closed  and  in  the  dark,  and  they  are  more  or  less  influenced  ])y  the 
<.'Oudition  of  the  ocular  muscles  generall}'.  According  to  Kirchhoff 
loc.  cit.,  p.  48):  "If  the  sensorial  deception  deveh»ps  in  one  eye  aloiu', 
the  possibility  of  distinguishing-  it  from  a  unilateral  hallucination  which 
has  developed  centrally  is  to  be  sought  in  the  fact  that  the  central  devel- 
opment gives  rise  to  nuich  more  complicated  phenomena."  The  explana- 
tion of  a  unilateral  hallucination  would  naturally  lead  us  to  consider  the 
X)hysiological  pathology,  and  to  look  for  some  affection  of  the  (X'cipital 
lobes.  It  has  been  i)ointed  out  that  in  paretic  dementia  in  which  the 
frontal  lol)es  are  most  frequently  affected,  there  are  seldom  hallucina- 
tions ;  but  in  those  cases  where  tliis  s^'mptom  has  occurred  the  occipital 
lobes  have  been  found  to  be  diseased. 

Unilateral  halJucination  of  vision  can  be  explained  b}'  some  disease 
of  the  optic  commissure,  or  of  the  nerve  nuclei  of  one  side  of  the  brain. 

Auditory  hallucinations,  which  may  be  of  a  very  simple  kind,  or, 
on  the  other  hand  (as  in  the  case  of  optical  perversion),  may  form  the 
basis  of  mental  ndstakes,  are  varied  in  their  causation  and  occurrence. 
They  perhaps  more  frequently  have  a  deeper  and  nu)re  alarming  signifi- 
cance than  the  others,  are  not  so  easily  corrected,  and  are  more  gen- 
■eral  in  occurrence  than  any  other  hallucinations.  They  usually  consist 
-of  the  recognition  of  the  sound  of  imaginary  voices  and  the  repetition  of 
many  ordinary  sounds.  A  distinctly  insane  hallucination  of  hearing  has 
nearly  always  valual)le  diagnostic  significance,  for  the  reason  that  it  in- 
dicates a  more  general  derangement  than  those  of  the  other  senses.  A 
person  may  readily  have  such  a  sane  hallueination  as  hearing  an  imagi- 
nary voice,  as  the  result,  possildy,  of  an  irritation  of  the  middle  ear;  but 
the  insane  individual  expresses  his  fear  of  the  sounds  of  voices  speaking 
through  a  telephoue,  the  register,  or  cracks  in  his  room ;  or,  in  a  more 
disorderly  conditiou,  it  is  the  figures  in  the  pictures  upon  the  wall  who 
iire  addressing  him. 

Amlitovtj  ]ial]i(ci)iafi(nis  that  convey'  no  suggestion  of  insanity,  like 
all  other  ordinary  false  perceptions,  are  nearly  always  immediately  re- 
moved, are  recurrent  in  the  original  form,  and,  of  course,  are  not 
associated  with  other  evidences  of  derangement.  The  auditory  halluci- 
nations of  the  insane  patient  form  the  basis  of  communications  from 
divine  personages,  from  invisible  friends  or  others,  who  connuand  him 
to  perform  various  acts,  and  he  cannot  be  convinced  of  his  error  even 
Avhen  his  environment  is  changed  and  certain  objects  are  remo\'ed  which 
facilitated  the  creation  of  the  hallucination  itself. 

There  is  a  light  grade  of  purely  mental  aiulitory  hallucinatory 
disturbance  that  I  have  seen,  and  it  is  in  some  nieasm'c  hysterical,  the 
full  inmge  being  called  up  at  will,  and  the  patient's  declaration  and  be- 
havior doing  away  with  any  real  su])position  that  the  ear  or  eye  is  at 
fault.  I  have  recently  seen  a  case  of  tins  kind,  where  the  suspicion  that 
an  auditory  hallucination  existed  was  at  first  very  strong,  but  frequent 
interviews  convinced  me  that  when  the  patient  turned  in  one  direction  and 
-addressed  an  imaginary  person,  such  an  act  was  led  up  to  by  an  incoher- 


32  ^   SYSTi:2I  OF  LEGAL  MEDICIXE. 

ent  couversation,  in  wMcli  tlie  response  to  tlie  imaginary  mandate  was- 
l^rompted  by  a  pre\ious  train  of  thonglit ;  and  when  I  asked  her  if  the 
l^ersons  she  addressed  were  near  her,  she  rephed,  "No,"  but  that  she  was- 
talking  to  them  hi  the  spuit.  The  consequences  of  hallucinatory  man- 
dates and  subsequent  delusions  are  apt  to  sometimes  be  serious,  and 
those  cases  where  patients  refuse  food  and  drink  because  they  are  toki 
to  do  so  liy  imagiuar}-  persons  are  often  obliged  to  submit  to  compulsory 
feedmg,  or,  if  this  is  not  done,  death  by  starvation  ensues. 

Hallucinator}^  voices  may  be  bilateral  or  unilateral,  external  or  inter- 
nal, and  are  not  so  common  at  night  as  in  the  daytime  when  the  patient 
is  awake. 

Olfactive  hallucinations  are  exceedingly  rare,  and  may,  like  the 
others,  have  a  local  or  a  central  basis.  Perversions  of  both  taste  and 
smell,  therefore,  may  result  from  some  actual  local  condition,  such  as 
decomposition  of  epithehum  in  the  mouth,  bad  taste,  offensive  discharges,. 
etc.  Sometimes  these  conditions  lead  to  well-marked  delusions,  which 
are  amplified  usually  in  the  direction  of  the  horrible. 

The  odor  of  decayed  matter  suggests  that  of  a  dead  bod}',  Avhile  re- 
fusal to  eat  is  the  result  of  a  delusion  of  poisoning.  There  are  a  class  of 
purely  central  hallucinations  of  this  character  which  owe  their  origin  to 
some  disease  of  the  oKactory  nerve  itself,  or  probably  to  the  uncinate 
gji-us.  Such  a  case  I  have  elsewhere  reported,  where  occasionally  hallu- 
cinatoiy  perception  of  the  odor  of  smoke  was  a  symptom,  and  a  sub- 
sequent autopsy  revealed  extensive  disease  of  the  region  above  mentioned. 
However,  the  patient  is  nearh^  always  able  to  recognize  the  source  of  his 
trouble ;  but  when  he  does  not,  we  may  then  account  for  such  a  per\-er- 
sion  as  an  incident  due  to  insanity. 

What  are  known  as  hallucinations  of  feeling,  and  what  are  really  per- 
verted or  false  perceptions  of  the  skin  and  its  appendages,  the  visceral 
organs,  or  an  alteration  of  what  is  known  as  the  muscular  sense,  are 
s^Tiiptoms  both  of  the  lighter  psychoses  as  well  as  of  the  graver  forms- 
of  mental  disease,  and,  Hke  the  other  hallucinations  previous^  mentioned, 
maj^  not  at  tunes  be  attended  by  any  considerable  intellectual  impair- 
ment. They  play  an  important  part  in  hjqjochondi-iasis,  and  in  that 
affection  of  Ihnited  intellectual  disturbance  known  as  piiranoia,  where 
one  or  two  dominant  illusions  exist.  Theii'  range,  however,  is  usually 
very  wide. 

Distnrhances  of  muscular  sense  lead  to  a  variety  of  perverted  percep- 
tions, indi\iduals  declaring  that  they  have  been  depris'ed  of  certain  mem- 
bers, or  that  one  part  of  the  body  or  the  other  is  al)sent.  A  common  ex- 
ample of  this  form  of  hallucuiation  is  that  in  which  the  individual  who 
has  imdergone  anii^utation  declares  that  he  feels  the  presence  of  the  lost 
limb.  Sometimes  these  hallucinations  are  pleasiu-able  and  expansive, 
thougli  very  often  they  are  associated  Avith  mental  distress  and  not  un- 
rareh-  lead  to  suicide.  They  very  often  cause  the  victim  to  declare  that 
he  is  being  subjected  to  some  occult  influence,  that  he  is  being  mesmer- 
ized, or  is  the  subject  of  punishment  inflicted  by  others.  Of  course, 
under  these  circumstances,  the  halhieination  is  the  basis  of  a  delusion. 

Seasoned  hdJJucinafions  sometimes  have  an  important  significance 
in  the  form  of  sexual  perversion. 

Curious  cases  are  recorded  where  women  prefer  the  most  absurd 
charges  of  assault,  or  imagine  themselves  impregnated  or  sexual!}^  de- 


jysjyiTV  IX  ITS  mi:divu-li:(ial  ukakixcs.  33 

formed,  as  the  result  of  sensorial  hallueinations.  I  liave  seen  several  men 
"svho  tlironi>'li  siieli  a  derang'ed  mental  state  believed  themselves  i)ref^'nant. 

As  l)efoi-e  stated,  the  exi)i'ession  of  hallucinations  of  all  kinds  is  very 
irre<i'nlar,  and  does  not  necessai'ily  indicate  insanity.  We  find  everywhere 
in  lilci'atnre  instances  of  false  pt'rceptidii,  some  of  whicli  ai'e  historical  and 
familiar.  Lombroso  [Thi'  Mun  of  (ji'hiks,  London,  1S91,  p]).  ."jG,  57;  has 
<'olleeted  nnmerons  examples,  as  has  also  Brierre  de  Boismont.  Brutus 
•Caesar  and  Napoleon  had  simple  hallucinations,  those  of  the  latter  being 
evidently  due  to  some  circulatory  disturbance  incident  to  exhaustion. 
Shelley  Ihonu'ht  he  saw  a  child  arise  from  the  sea  and  clap  its  hands. 
Bunyan  lieai-d  voices.  Byron  imagined  that  he  was  haunted  l)y  a  specter. 
Dr.  Johnson  distinctly  heard  his  mother  call  him  "Samuel,"'  althoug'h 
.she  was  not  present.  Goethe  saw  his  own  image  connng  to  meet  liim, 
.and  Van  llelmont  declared  that  he  had  seen  his  own  soul  in  the  form  of 
.a  l)rilliant  crystal.  "  When  Oliver  Cromwell  was  lying  on  his  bed,  kept 
awake  by  extreme  fatigue,  the  curtain  opened,  and  a  "woman  of  gigantic 
proportions  appeared  and  announced  that  he  would  l)e  the  greatest  man 
in  England."  Some  of  these  cases  probaljly  belonged,  to  the  condition  of 
.send-consciousness  or  troul)led  sleep.  Others  were  due  to  fatigue,  and. 
still  others  to  genuine  mental  aberration.  Dr.  Johnson,  as  is  well  known, 
presented  a  form  of  mental  disorder  which  is  now  recognized  as  folie  du 
■(Joiite,  which  however  is  not  usually  accompanied  by  hallucinations. 

The  JiaUnciiiafioiis  of  acute  alcoJioJisiii,  as  well  as  those  due  to  Cdiniahis 
Indica,  opium,  and.  numerous  derivatives  of  the  ^oJanacecu — helJadonna, 
Jifjosci/anius,  etc. — are  examples  of  exhaustive  or  toxic  causation. 

It  is  j)ossible  to  induce  various  hallucinations  by  lii/puofir  suf/gesfion, 
.and  they  are  b}'  no  means  uncommon  accompaniments  of  those  dramatic 
hysterical  states  which  are  so  commonly  Avitnessed  in  France.  In  women 
they  not  unrarely  have  a  sexual  relation. 

Hallucinations  are  found  Alone  and  Together. — It  is  rare  for  a 
:single  hallucination  to  last  for  any  length  of  time,  exce^jt  possiljly  when 
it  is  of  an  auditory  character,  and  in  this  case  such  an  occurrence  is  rea- 
sonable when  we  consider  how  important  and  general  is  the  excitement 
Avhicli  stimulates  the  word-syml)ol  centers,  that  play  so  important  a  part 
in  the  operation  of  all  thought.  So  far  as  the  connection  of  hallucina- 
tions with  particular  forms  of  insanity  is  concerned,  it  may  be  said  that 
they  are  more  frequently  met  with  in  acute  mental  disease. 

In  primary  delusional  insanity  or  jjaranoia,  in  confusional  insanity, 
in  conditions  where  the  nerve  centers  are  poisoned,  especially  in  alcoholic 
insanity,  in  the  insanity  which  is  the  residt  of  fevers,  we  find  halluci- 
nations to  be  a  common  symptom,  and  they  are  always  increased  or 
•developed  by  seclusion.  Hallucinations  are  not  only  a  common  result 
■of  solitary  confinement,  1>ut  are  expressed  at  night,  when  the  patient  is 
alone,  and  when  sleep  is  fitful,  and  the  insane  person  indulges  in  noisy 
outbreaks.  As  Lewis  {A  Text-hool-  of  Menial  Diseases:,  p.  1G7)  has  pointed 
out,  such  indiA'iduals  are  benefited  by  removal  to  an  associate  dormitory. 
"  Such  hallucinations,"  says  he,  "  often  peculiarly  vivify  and  fascinate 
the  mental  vision,  and,  according  to  their  nature,  call  iov{\\  correspond- 
ing results.  The  patient  may  be  passionate,  wild,  threatening,  and 
defiant,  shouting  an  alarm  for  succor;  joyous,  exultant,  or  in  a  l)oisterous 
merriment.  Every  phase  of  emotional  life  may  present  itself  as  the  hal- 
lucinations varv  and  he  enacts  his  little  drama  alone.  ...  In  general 


34 


A   SYSTEM  OF  LEGAL   MEDICLXE. 


paralysis  these  noetnrnal  orgies  are  frequent,  noisy,  i-estless,  with  or  mth- 
out  hallucination,  aecompanpug  the  latter  stages  of  most  cases." 

A  talkie  prepared  by  Dr.  Edward  B.  Lane  is  reproduced,  which  mil  l">e 
of  service  in  showing  not  only  the  kind  and  extent  of  hallucinations,  but 
the  forais  of  insanity  in  which  they  aj^pear.  {Boston  Medical  and  Surgical 
Journal,  vol.  cxxv.,  Xo.  11,  p.  268.) 


1 

1 

Si^ 

■« 

rfS 

.^ 

1 

1 

B 

^. 

« 

. 

<>2 

^-' 

E-i 

^i- 

^ 

^ 

s 

S 

S 
C3 

t 

1 

t 

^■ 

^ 

s 

!> 

«S 

& 

1^ 

8 

[Ss 

s 

i 

■| 

s- 

t 

2 

fc: 

to 

<? 

!=1 

fe! 

fe: 

fc: 

^ 

^ 

^ 

Paranoia 

RS 

1 

1 

IS 

^ 

0 

1 

1 

fi7 

Acute  melaneliolia 

?i''> 

9 

4 

f) 

55 

' '      mania 

15 

3 

20 

38 

Pai'etic  dementia 

C) 

2 

1 

3 

19 

34 

Post-paralytic  insanity 

1 

2 

7 

10 

Other  organic  brain  disease 

3 

2 

"1 

6. 

Epileptic  insanity 

4 

4 

8- 

Insanity  of  pubescence 

4 

2 

0 

11 

Katatonia 

2 

4 

Hysterical  insanitj' 

1 

5 

6. 

Senile  insanity 

fi 

5 

0 

16 

'^9 

Alcoholic  insanity 

1 

_; 

2 

3^ 

KecuiTent  mania 

1 

3 

4 

Folic  du  doiite 

1 

1 

Simple  mania 

2 

2' 

"        melancholia 

10 

10 

Folic  circiilairc 

7 

( 

Senile  dementia 

•• 

6 

6 

114 

19 

o 

47 

10 

2 

1 

1 

105 

301 

The  appearance  of  hallucinations  in  primary  delusional  insanity  has- 
been  referred  to,  and  in  such  a  condition  they  are  usually  persistent,  and 
form  a  basis  of  that  variety  kno^vn  as  the  sensorielle  YerriicWieit,  in  which 
some  delusions  owe  their  origin  to  perverted  perceptions  originating  in 
the  skin  or  the  ^dsceral  organs.  In  other  cases,  delusions  of  persecution 
and  susiDicion  spring  directly  from  hallucinations  of  hearing  and  seeing. 

ILLUSIONS. 


An  illusion  is  a  distorted  percei^tion  of  an  objective  reahty ;  in  other 
words,  it  is  the  false  i)ercei3ti(ni  of  something  that  has  an  existence. 

Illusions  are  like  hallucinations  in  their  classification — they  may  be 
of  various  kinds,  and  are  due  largely  to  local  disease ;  and  while  some- 
times as  elements  of  insanity  they  are  l\y  no  means  so  important  as  the 
forms  of  false  perceptifju  just  descril)ed,  Avhicli  have  no  objective  basis, 
may  originate  more  or  less  stul)boru  delusions,  or,  on  the  other  liand, 
may  often  lie  easily  corrected  l)y  their  possessor. 

The  distinction  between  an  illusion  and  hallucination  may  be  illus- 

*  And  touch. 


7XSJ.\77T   IX  ITS   MKDira-LKdAL   Jli:Ji;iXGS.  35 

trated  as  follows  :  if  a  person  looks  at  a  tree  and  sees  two,  it  is  an  illnsion  ; 
if  he  declares  that  he  sees  a  tree  where  none  exists,  it  is  an  hallneination. 
If  he  niisinterpi'ets  the  sound  of  a  rin<;inu-  bell,  it  is  an  illusion  ;  if  he  says 
that  he  hears  a  bell  when  none  has  rung-,  it  is  an  hallucination.  Psyeluj- 
logically,  the  processes  consist  in  the  inability  to  coin})reliend  the  nature 
of  a  physical  inipressicni,  an  imperfect  concept  beinj>:  the  result  of  a  false 
perception  upon  which  an  imperfect  judgment  has  been  passed. 

In  an  hypnotic  condition  or  one  of  exagg-erated  receptivity,  an  indi- 
vidual is  very  apt  to  make  illusional  mistakes  in  identity,  which  would 
be  out  of  the  question  under  other  circumstances ;  so  that  it  is  not  un- 
usual for  insane  peoi)le  to  eventiudly  have  distinct  delusions  of  person- 
ality, which  are  due  to  their  false  ai)})reciation  of  the  figure  and  form  of 
some  person  wlioni  they  have  possibly  never  seen  before.  Like  halluchui- 
tions,  illusions  are  common  in  alcoholic  insanity,  as  well  as  in  paranoia 
and  coufusional  insanity,  and  sometimes  exist  as  a  symptom  of  paretic 
dementia. 

DELUSIONS. 

A  delusion  is  a  false  belief,  and  nuiy  be  regarded  as  sane  and  insane. 
Under  the  former  head  are  grouped  all  forms  of  eiToueous  or  unusual 
beliefs  which  many  individuals  entei-tain  whose  mental  integrity  is  un- 
questioned. These  latter  may  be  simply  the  offspring  of  ignorance  or 
prejudice  or  misinformation,  and  unless  they  be  the  fruit  of  religious  or 
other  dognuis  may  be  easily  removed  l)y  sufficient  evidence.  When  be- 
liefs are  held  wliich  to  nuiny  seem  unreasonable,  l^ut  are  nevertheless 
shared  by  a  sufficient  number  of  people  to  be  simply  matters  of  faitli, 
they  still  need  not  be  the  product  of  diseased  reasoning,  though  often- 
times the}^  are  eccentric  and  troublesome  to  the  world  at  large.  No  one 
would  think  of  questioning  the.  mental  health  of  the  large  rehgious  sects 
that  believe  in  the  immaculate  conception  or  the  miracles  of  Roman 
Catholicism,  the  doctrine  of  Swedeuborgianism  or  spiritualism,  any  more 
than  they  would  the  sincerity  of  a  great  majority  who  hold  to  any 
other  faith  the  elements  of  which  are  mor<^  or  less  inexplicable.  It  is, 
however,  when  extravagant  belief  obtains  such  complete  possession,  or  is 
connected  with  clearly  erratic  behavi(n-,  that  our  doubts  of  the  sul)ject's 
sanity  arise.  So  long  as  the  spirit}ualist  has  or  pretends  to  have  com- 
munication w4th  visible  spirits,  and  so  long  as  his  hallucinations  or  illu- 
sions or  delusions  do  not  tincture  his  conduct  in  a  way  that  makes  him 
a  nuisance  to  his  fellows,  the  law  concerns  itself  but  "httle ;  Init  Avhen, 
as  the  result  of  a  delusion,  a  crime  is  connnitted  or  a  foolish  business  act 
is  (umsummated,  we  more  seriously  ([uestion  his  responsibility.  The  law 
is  exceedingly  merciful,  if  not  lax,  in  its  attitude  toward  such  individ- 
uals, and  is  disposed  to  accept  excuses  that  may  be  offered  as  a  defense. 
I  can  recall  a  case  where  a  large  amount  of  money  had  been  left  by  an 
eccentric  Frenchnuin  to  a  philanthropic  society  for  the  suppression  of 
cruelt}'  to  auinuds,  and  for  the  s])ecial  care  of  eats.*  His  will  was  con- 
tested, and  liesides  peculiarities  of  manner,  it  was  the  subject  of  contest 
by  reason  of  this  seeming  nuirk  of  insanity.  It,  however,  transpired  that 
the  testator  had  been  tov  years  a  consistent  l)eliever  in  metempsychosis, 
and  was,  naturally,  anxious  that  his  transferred  soul  should  l)e  well  taken 
care  of  after  his  demise. 

*  Tlio  Bonavd  Will  Case. 


36  ^   SYSTEM  OF  LEGAL  MEDICLXE. 

In  Catliolie  countries,  where  large  nnmbers  of  people  believe  in  visions 
and  miracles — such  belief  oftentimes  being  primarily  based  upon  the 
donbtfiil  testimony  of  a  hysterical  girl  or  some  equally  unrehable  ol)- 
server — it  does  not  do  to  too  closely  qnestion  what  most  of  the  world 
wonld  consider  delnsions.  In  a  fnture  time,  when  the  stndy  of  the  gen- 
esis of  religions  belief  is  more  thorongh  than  it  now  is,  and  when  pathol- 
ogists and  psychologists  are  brave  enough  to  consider  the  sn])ject  from 
a  material  standpoint,  much  of  the  present  uncertainty  will  be  removed, 
and  it  will  be  possible  to  estimate  the  mental  integrity  and  illogical 
organization  not  only  of  many  existing  forms  of  faith,  bnt  of  the  new 
and  hastily  digested  varieties  of  fashionable  religion  that  crop  to  the 
sm'face  from  time  to  time  and  are  little  more  than  vents  for  those  in 
search  of  notoriety  or  of  emotional  excitement  to  find  relief.  I  am  in 
possession  of  a  large  amount  of  manuscript  which  throws  a  good  deal  of 
light  upon  this  subject,  and  I  think  my  exiDcrience  is  shared  by  other 
students  of  mental  medicine,  namely,  that  much  that  is  accepted  by  rep- 
resentative behevers  who  are  searching  for  sensations  has  its  origin  in 
the  insane  asylums.  In  this  connection  I  append  the  statement  of  a 
paranoiac  patient,  whose  theories  are  explained  by  his  disease.  This 
man,  like  others,  lived  for  some  time  in  a  community  mthout  attracting 
attention  to  his  real  state,  and  found  sjanpathizers  and  believers. 

In  acfiordanee  with  j-oui'  expressed  wisli  that  I  wi'ite  yon  a  statement  of  events  in 
my  life  which  happened  from  the  time  of  my  retin-n  from  Europe,  February  7,  1876, 
until  the  present  time,  January  6,  1878, 1  i^roceed  as  follows.  I  will  freshen  yoiir  recol- 
lection by  brief  reference  to  the  chief  points  of  my  education  up  to  the  beginning  of  this 
time.   Earl}'  home  training  and  general  schooling  usual  for  Christian  families.    General 

university  study.     Graduation  in Medical  Department.     I  went  to ,  opened 

an  office  in  one  of  the  best  buildings  there,  lived  at  the  best  hotel,  boarded  a  valuable 
team  which  had  been  presented  to  me,  and  my  expenses  ran  $150  per  month,  only,  as 
I  supposed,  consistent  with  my  reasonable  expectations  on  the  education,  and  my  at 
least  presumable  professional  attainments.  I  ijursued  the  usual  course  among  people — 
went  to  church,  extended  my  acquaintance,  did  some  iDrofessional  business  about  the 
hotel  among  Christians  and  Jews,  had  one  or  two  misunderstandings  on  the  matter  of 
charges  (verj-  unpleasant  to  me).  Received  scarcely  any  business  from  the  city,  though 
my  card  was  very  conspicuous  in  the  city  column  of  the  daily  paper — simply  name, 
residence,  office,  and  telephone  nimiber.  I  met  several  of  the  best  citizens.  At  the 
hotel  at  this  time  a  gentleman,  evidently  one  of  the  best  citizens,  was  living.  I  saw 
him,  and  rememljer  of  thinking  at  the  time,  "  Now,  tliere  is  one  of  the  best  citizens  ;  he 
can  ax^preciate  my  merits,  so  I  will  not  crowd  myself  upon  liim."  In  tlie  dining-room 
of  the  hotel  I  happened  to  be  seated  full  face  to  the  entrance,  but  a  goodly  distance 
away.  Times  were  active,  and  man^^  people  came  in  and  out.  One  noon  a  young  and 
stately  lady  came  in,  a  young  gentleman  beside  lier  (her  brother).  I  noticed  strangely 
apparent  evidences  of  her  disposition  for  me — this  upon  several  occasions — so  much 
so  that  one  daj'  I  placed  my  glasses  on  to  scrutinize  her  closely.  After  two  or  three 
manifestations  of  her  preferment  I  noticed  her  in  company  with  her  mother  (a  lady, 
to  my  mind,  of  the  right  tj-pe) ;  then  the  gentleman  mentioned  before  as  a  respectable 
citizen  living  at  the  hotel  was  with  her.  It  now  became  ajiparent  they  were  all  of  one 
family — father,  mother,  daughter,  and  two  brothers.  Of  all  I  liked  the  appearance  and 
conduct.  The  yoimg  lady's  expressions  went  on  ;  then  I  fell  in  love  with  her.  The 
passion  grew  upon  me,  possessed  me,  ran  away  with  me.  At  approaching  Christmas 
I  sent  her,  before  having  met  lier,  a  large  basket  of  flowers  with  my  name  down  in  tiie 
middle  of  them.  These  the  mother  returned,  saying  on  a  note  she  could  not  allow  her 
daughter  to  receive  presents  from  gentlemen  with  whom  she  was  unaccpiainted.  But 
before  this  I  had  met  the  fatlier  and  asked  him  for  an  introduction  to  the  family.  I 
sent  a  card  and  called,  met  tlie  mother  and  brothers,  but  a  meeting  with  the  daughter 
wa-j  prevented — evidently  until  they  sliould  satisfy  themselves  from  others'  say-so  as 
to  me:  who,  wliat,  whence,  value,  etc.,  etc.  The  girl  seemed  to  me  the  entire  fulfill- 
ment of  all  my  early-life  impressions,  and  all  my  desires  might  ask.     I  loved  her  in- 


JXSAXITY  IX  ITS   MKDlCO-LKdAL    JU:.H;i.\(!S.  37 

tensely.  In  this  love  my  ileveloi)moiit  was  completed.  I  ■wrote  llie  mother  several 
times  to  introduce  ns,  but  was  not  ji^nititied.  I  thought,  too,  they  favored  our  atTec- 
tions,  and  I  supposed  tlieir  mctliod  would  b(>  tlieir  own  ;  and  ])robably  a  party  at  their 
house,  or  at  that  of  a  frieml's  family  also  at  that  tiiiic  at  tlic  hotel,  but  pieseiitly  to 
move  into  an  home.  The  family  with  the  young  lady  moveil  from  the  hotel  into  their 
home  in  the  city.  We  were  thus  estranged.  Anotiier  family,  friends  of  theirs,  came 
to  the  hotel,  as  I  believed,  to  encourage  me  meeting  them.  Tliis  I  wouiil  not  do  by 
finy  volition  of  my  own.  I  was  resolved  if  they  had  anything  to  say  they  must  say  it 
in  unmistakable  language,  for  by  now  I  was  out  of  all  .sympathy  with  them  at  their 
inhunuin  conduct,  but  still  loved  the  daughter.  The  season  at came  on.  I  con- 
tinued my  ofKce  in  the  city,  and  by  appointment  of  the  manager  of  the Hotel  I 

kept  hours  thei'e  too,  it  being  but  a  half-hour's  run  between.     At another  family, 

friends  of  the  first,  came  to  the  lake.  I  met  none  of  them  as  it  hapi)ened.  My  young 
lady  came  out  to  visit  them.  I  wrote  her,  asking  privilege  to  meet  iier;  got  no  reply. 
Asked  an  interview  with  the  old  lady  she  was  visiting;  got  it,  explained  tjie  situation, 
and  asked  lier  for  an  introduction  to  the  young  lady.  She  thought  it  would  be  Avrong, 
as  she  was  their  guest.  The  next  day  they  went  boating ;  came  direct  from  the  lake 
to  their  train,  where  the  young  lady's  mother  received  her  and  took  her  to  the  city. 
The  old  lady  at  the  lake  then  advised  me  to  see  the  young  lady  at  her  home  or  write 
her,  and  to  do  so  at  once.  Accordingly  1  wrote  her  fully,  the  season  at  the  lake  being 
•ended.  I  got  no  answer,  but  a  brother  came  next  day  to  the  hotel  and  dined  with 
their  friends.  Next  day  the  j'oung  lady  came.  By  this  time,  the  proceeds  of  business 
not  having  been  up  to  exjiectations,  I  was  being  closed  down  upon  by  creditors.  A 
friend  u})on  whom  I  had  i-elied  came  and  helped  me  out,  and  refused  to  coiiperate  with 

me  in  any  further  operations  in .     I  would  not  leave  without  an  expression  from 

this  young  lady.  My  friend  went  to  the  father  for  tliis,  and  In-ouglit  me  word  that 
the  young  lady  despised  me.  I  then,  much  oppressed,  had  nothing  to  do  but  to  go 
away.     I  went  to  Jonestown. 

In  Jonestown  I  opened  an  office,  resolved  now  at  all  hazards  to  be  independent  of 
any  one.  I  was  thirty  years  of  age,  and  determined  to  make  my  profession  support 
me  now,  or  starve  out  of  it  into  something  else  or  into  death.  After  so  much  educa- 
tion and  so  many  anxieties,  I  resolved  I  would  prefer  death  rather  than  be  on  any 
one's  charity,  and  besides  felt  that  educational  impressions  had  not  confirmed  and 
verified  themselves.  I  went  on,  managed  to  live  also  in  my  office — one  room — reduced 
expenses  to  $4.5  a  month,  went  to  chiu-ch,  and  extended  acquaintance.  Notwithstand- 
ing all  this  I  had  to  borrow  money.  I  borrowed  of  some  Jews  doing  business  in  the 
same  building,  at  a  high  percent.  I  made  some  money,  and  was  getting  on  pretty 
well,  and  was  being  encouraged  by  the  leading  physician  of  Jonestown.  I  paid  my 
rent  according  to  statutory  requirements  and  consistent  with  the  tmderstanding. 
However,  I  was  peremptorily  summoned  to  court  (illegally,  as  I  can  show)  for  balance 
of  rent  and  possession  of  the  place.  At  the  justices'  court  I  presented  my  case  (being 
too  poor  to  obligate  myself  to  a  lawyer).  It  seemed  a  simple  case  of  rights,  and  I  was 
•confident.  However,  a  judgment  was  given  against  me — an  unholy  and  an  unright- 
eous judgment,  as  I  can  shoir.  The  officers,  a  few  days  later,  came  down  on  me  for 
the  rent  and  possession  given  in  the  judgment.  I  paid  the  rent  then  np  seA"enteen 
<lays  head,  so  I  was  left  in  possession.  I  tried  then  to  induce  the  owner  not  to  insist 
on  posses.sion.  I  found  him  determined,  and  learned  that  he  was  in  a  combination 
with  my  neighbor,  also  a  doctor,  to  give  the  latter  mj'  place,  and  it  became  apparent. 
be\'ond  all  dispute,  this  doctor  is  an  ignoble  character.  They  kept  on  with  their  plot 
(every  detail  of  which  I  can  prove).  I  tried  to  obviate,  circumvent,  and  even  to  allow 
them  to  execute  their  judgment  with  failure  to  themselves,  nntil  I  saAv  it  was  abso- 
lutely inijiossible  as  by  methods  common  among  gentlemen.  I  saw  they  were  deter- 
mined to  cari'y  out  their  execution,  which  meant  to  me  now  a  deprivation  of  business, 
office,  home,  and  living,  and  I  saw  if  they  went  on  their  way  it  meant  a  sacrifice  of  all 
honor  to  me  and  manhood.  I  determined  it  could  not  end  their  way,  for  thoiigh  they 
had  the  law  and  power  I  liad  }-i(/ht.  1  resolved  it  should  end  my  way;  accordingly, 
with  my  knowledge  of  man,  I  resolved  on  a  gunpowder  policy,  and  knew  my  experi- 
•ences  would  give  me  the  nerve.  I  realized  my  good  name  would  be  ptit  in  hazard, 
and  what  I  gained  would  be  contestable  ;  but  relative  to  the  matter  in  hand  I  intended 
to  apply  my  way,  let  come  what  would :  even  death  woidd  have  been  preferable  to  re- 
signing every  Imman  feeling  V)y  running  away  from  my  defensible  rights.  Knowing 
tlie  possibility  of  meeting  death — for  the  pro]>rietor  had  himself  been,  as  iu^  from  time 
to  tinu^  had  told  nu',  a  '"Western  tough  "—I  sat  dowji  the  night  before  the  day  I  in- 
tended to  proceed,  and  wrote  out  my  position,  intention,  and  referred  to  possible  re- 
sults, also  stating  my  beliefs  in  religion,  views  on  God,  conclusions  on  my  life  up  to 


38  J.   SYSTEM   OF  LEGAL   MEDICLXE. 

this  time,  and  changes  in  opinions  on  these  suljjects  I  thought  it  desirable  should  be 
made.  I  outlined  these  only  briefly,  as  I  did  not  have  time  to  elaborate,  saving  if  I 
fell  I  might  desire  to  see  these  things  done  by  others.  If  I  died  I  knevr  tliis  would  be 
found  in  my  desk.  Next  morning  I  went  with  a  receipt  for  $20.  also  a  golden  eagle. 
and  a  lease* for  six  months.  I  laid  down  the  money  and  receipt  before  the  proprietoi" 
of  the  building,  on  his  desk  in  his  office.  Said  I.  "  There  is  Jf20  and  a  receipt  for  it ; 
sign  that."  He  took  it,  looked  at  it.  and  said,  "  Well,  I  don't  hare  to  if  I  don't  want 
to.''  Said  I.  "Yes.  you  do.''  and  "covered"  his  face  with  a  38-ealiber  I'evolver  (S.  & 
W.).  He  exclaimed.  '•  Well  I  "  I  saw  he  hesitated,  and  I  must  unnerve  him.  I  raised 
the  gun  over  his  head  and  fii-ed  iu  the  brick  wall,  high  up.  Tliis  brought  him  and  two 
other  men.  who  were  in  the  office  at  the  same  time,  to  their  feet.  The  two  others 
came  toward  me.  and  I  supposed  would  seize  me,  so  I  "'pulled  down ""  on  them,  held 
them  at  bay.  and  annotmced,  "He"s  got  to  sign  that  receipt.""  He,  meantime,  was 
exclaiming." "I'll  sign  it  I  111  sign  it  I "'  and  he  sat  down  and  did  sign  it.  He  got  up 
and  handed  it  to  me.  I  then  gave  him  the  lease  ;  he  took  it.  I  said,  "  There  is  a  lease 
for  six  months  ;  sign  that."'  "I'll  sign  it ! '"  he  said.  He  did  so.  I  then  emptied  the 
pistol  in  his  waUs,  excepting  one  ball.  This  I  did  because  I  knew  the  facts  would 
come  out.  and  as  an  evidence  of  no  more  use  for  such  forces  ;  to  show  only  those  ends 
may  be  attained  by  war  which  may  be  reached  by  peaceful,  honorable  means  among 
fully  accomplished  men.  The  fifth  and  last  ball  I  discharged  at  my  office  door,  near 
my  (lovely)  neighbor,  to  show  him  all  the  forces  to  be  considered  in  such  foul  designs 
as  his ;  but  while  we  had  them  we  also  knew  how  to  control  and  dii-ect  them,  but  could 
reach  our  ends  and  prove  our  course  if  given  a  fair  chance.  I  now  went  to  sell  the 
lease,  to  increase  its  possible  value,  and  intended  to  sell  at  almost  any  figure.  The 
value  was  $90.  Wlien  I  came  to  the  street  cries  of  "  There  he  is  !  take  him  !  kill  him  I  " 
etc..  etc.,  were  expressed.  I  was  arrested,  taken  to  the  police-station ;  the  jn-oprietors 
swore  in  a  charge  of  assault  with  intent  to  kill.  I  explained  it  was  not  so — I  only  had 
insisted  on  his  signature.     One  gentleman  spoke  up  and  said.  '•  Hello.  Doctor,  what's 

the  matter?"'     This  gentleman  was  a  ilr.  Z ,  a  Jew.     The  officers  took  me,  locked 

me  in  a  cell.     Mr.  Z protested,  and  said  he  would  go  my  bail.     They  fixed  iip  the 

yjapers.     I  was  taken  to  coui-t.     The  charge  was  read.     I  denied  it.     Bail  was  fixed  at 

$750.    Mr.  Z signed  the  certificate,  and  trial  was  set  for  a  hearing  next  day.    I  was 

released.  The  widt  for  ejectment  was  served  on  me  Good  Friday.  I  refused  to  leave 
my  office.  The  officers  said  they  would  not  act  '•until  to-morrow  at  eleven  o'clock.'" 
At  that  time  they  came.  I  refused  to  go,  and  the  officers  di'agged  me  from  my  office. 
thus  using  their  execution  in  spite  of  me.     I  was  taken  to  the  hospital,  where  I  agreed 

to  stay  until  the  Iwnd  could  be  changed.     This  was  extended  indefinitely  by  ili'.  Z 

signing  a  new  bond  to  which  my  fi'iend  also  affixed  his  signature,  he  having  been  sum- 
moned by  wire.  While  at  the  hosj^ital  Easter  Sunday  I  desired  to  go  to  church,  luit 
was  not  allowed  to.  By  extension  of  the  bond,  and  the  deductions  I  wished  to  an- 
nounce from  all  this  treatment.  I  have  come  on  to  Xew  York  City.  I  shall  return  to 
Jonestown  for  my  trial.  My  execution  in  the  M-rit  of  the  landlord  was  served  and  exe- 
cuted at  a  remarkable  time  of  the  Christian  year.  viz..  Good  Friday.  I  was  dragged 
away  on  the  .Je'^^■ish  Smiday;  refused  attendance  on  chui'ch  Easter  Sunday.  Yester- 
day I  issued  the  following  proclamation  to  the  young  ladies  of  Jonestown :  "  I  call 
yotir  attention  to  the  treatment  I  have  received  at  the  hands  of  the  Christians,  and 
how  differently  the  .Jews  have  treated  me.  I  call  upon  yotx  to  demand  of  yom-  daily 
papers  an  open  statement  of  the  facts.  I  recommend  you,  unless  the  Jews  are  ad- 
mitted to  full  acknowledgment  and  given  fidl  and  equal  share  iu  all  the  joy  of  yotir 
coming  Easter  celebrations — I  recommend  you  not  to  dance."'  (They  are  getting  up 
an  elaborate  dance.) 

Xow,  you  will  notice  the  contrast  of  ti-eatment  which  I  have  received  from  Jews 
and  Chi-istians — an  equal  stranger  to  both.     Deductions :  that  defect  of  teaching  in 

religion  prevented  me  meeting  the  young  lady  of  E ;  these  defects,  as  medical 

men.  we  know:  I  refer  to  the  technicalities  and  rites  of  the  church — mystery  of 
incarnation,  resurrection.  Adam  and  Eve,  and  such  teachings  out  of  harmony  with 
natm-e  and  with  fact,  and  wrong,  leading  us  rapidly  into  dangers,  if  not  national  ca- 
lamity. These  dangers  are  not,  of  coiirse,  now  pai-ticularly  threatening.  I  tried 
Christianity  luider  the  old  cross,  and  found  but  half  a  Christ  and  lost  salvation,  I  do 
not  relinquish  Christianity,  but  in  keeping  it  insist  on  changes,  and  don't  want  salva- 
tion without  the  Jews,  for  I  think  they  for  1878  years  have  held  their  position  against 
the  unnatural  conception,  and  liaA-e  been  the  ^^ctims  of  mucli  persecutioii  which  tlie 
h\-pocrisies  of  Cliristianity  as  now  interjireted  are  responsible  for.  and  it  is  time  these 
things  stop.  This  virtually  brings  us  about  up  to  date,  and  tlie  elaboration  of  the  de- 
tails respecting  changes  ^vill  be  made  in  due  time.    When  I  left  Jonestown  I  promised 


IXSJyfTV   IX  ITS   MEDKO-LKdAL   BEARINGS.  3^ 

to  the  Jews,  throiif?li  my  friend  Dr.   K ,  my  body,  soul,  and  powers.     I  shall  do 

wliat  I  can  to  my  pui-poses,  iind  whether  tlie  Jews  ac<'e])t  the  otter  or  not  remains  to 
be  seen.  If  so  I  sliall  unite  tlie  Jews  witli  Christianity  in  tlesh  and  blood  under  tlie 
new  cross.  As  I  told  you,  our  niune  is  Christians  of  tlie  Starred  Cross.  I  realize  this 
is  but  a  beginning,  but  everything  must  start  so  and  grow. 

Before  this  was  written  he  had  perfected  a  complete  scheme  of  what 
he  intended  to  do,  liad  ordered  special  badges,  one  of  which  he  wore,  and 
perfected  the  details  of  this  new  "  Keliii'ion  of  the  Starred  Cross.-'  The 
case  is  reproduced  in  full  liecausi;  I  Ix'lieve  it  shows  most  fidly  the  gene- 
sis of  a  state  characterized  l>y  significant  ercjtic,  persecutory,  (pierulent, 
and  religious  insane  delusions  which  are  so  often  associated  in  cases 
which  find  their  way  into  the  courts,  and  where  juries  lose  sight  of  their 
real  nature,  considering  the  education  and  ordinary  behavior  of  the 
lunatifi. 

Without  pursuing  this  suT)ject  at  length,  I  may  refer  to  the  teachings^ 
of  Ltttlier  and  Swedenborg  and  other  fanatics,  whose  lives  were  filled 
with  plentiful  instances  of  the  same  behavior. 

Insane  delusions  are  those  which  concern  us  most  directly.  An  in- 
sane delusion  implies  the  holding  of  a  belief  in  something  which  has  no 
existence  except  in  the  diseased  imagination  of  a  person,  and  which  is 
not  removable  by  satisfactory  evidence  of  its  falsit}-.  Other  definitions 
have  been  given,  but  I  think  this  will  do  for  practical  use.  Spitzka  [In- 
mnifj/,  etc.,  p.  24)  calls  insane  delusions  ''faulty  ideas  growing  oat  of  a 
l)erversion  or  weakening  of  the  logical  apparatus."  Delusions  are  the 
outgrowth  of  a  mental  disorganization  wliicli  is  usually  far-reaching  and 
impli(_'S  a  certain  involution  of  the  mental  processes.  They  may  l)e  ec- 
centric and  centric,  dejiending  in  the  fii'st  instance  upon  hallucinations  or 
illusions  or  false  appreciation  of  external  objects,  or  they  may  be  en- 
tirely connected  with  the  subjective  condition,  the  identity  becoming  lost 
or  confused.  They  may  exist  severally,  together,  or  there  may  be  one 
more  or  less  dominant  delusion  which  is  repeatedly  and  consistently  ex- 
pressed. They  may,  of  course,  be  ex})ressed  in  speech  or  shown  in  man- 
ner, gesture,  and  dress.  They  may  be  h^gically  manifested  as  the  result 
of  a  more  or  less  common  train  of  reasoning  with  false  premises  (sys- 
tematized delusions),  or  they  may  be  disorderly,  confused,  and  entirely 
devoid  of  plausibility  (unsystematized).  The  first  very  often  go  with 
astonishing  vigor  of  intellectual  power  and  capacity  for  analysis,  such  as 
we  often  find  in  reasoning  insanity,  but  the  conclusions,  judgment,  and 
volition  are  impaired.  The  disorderly  or  unsystematized  delusions  are 
much  more  dramatic  and  betray  an  acute  denun-alization. 

A  systematized  delusion  has  s(une  basis,  and  the  dilference  between 
this  and  the  other  kind  may  be  illustrated  by  calling  attention  to  the 
fact  that  in  the  former  the  possessor  of  a  delusion  of  suspicion  or  per- 
secution may  pick  out  some  particular  i)erson  as  his  imaginary  enemy, 
giving  reasons  for  the  alleged  persecution — ])ossibly  connecting  the 
enemy  with  them — and  is  full  of  reasons  for  his  mental  attitiule  wliich 
are  nun-e  or  less  plausible ;  while  the  possessor  of  the  unsystematized 
delusion  makes  the  vagiu\^t  and  wildest  accusations,  complaining  of  ])er- 
sons  concealed  in  the  water-})ii)es,  referring  to  the  voices  of  imaginary 
enemies  who  are  cursing  him,  and  seems  to  have  no  basis  whatever  for 
his  absurd  Ix'lief. 

Systematized  delusions  are  usually  limited  in  number,  and  belong  to 


40  ^   SYSTEM  OF  LEGAL  MEDICINE. 

the  evolutional  insanities,  wliich  include  such  affections  as  paranoia; 
while  unsystematized  delusions  are  usually  plentiful,  and  are  very  often 
accompanied  by  the  incoherence  which  helong's  to  the  acquii'ed  and  so- 
matic insanities  or  to  the  involutional  jisychoses,  which  include  paresis^ 
and  dementia. 

The  genesis  of  an  insane  delusion  bears  a  proportionate  relation  to 
the  failure  of  the  object-consciousness,  while  the  subject-consciousness  is 
exerted;  as  Lewis  ijoc.  cH.,  pp.  126,  127)  expresses  it:  "As  subject-con- 
sciousness becomes  more  and  more  pronoimced,  with  failiu-e  of  object- 
oonsciousness,  all  impressions  ahke,  received  from  the  non-eg'O,  become 
the  pabulum  for  the  growth  of  an  all-pervading  egoism.  The  subject 
broods  over  his  multiform  and  novel  feelings — morbid  introspection  and 
egoistic  musings  replace  the  healthy  altruistic  feelings  and  sentiments, 
and,  since  the  emotional  life  is  itself  in  i3art  the  origin  of  rej)resentative 
cognitions  of  the  outer  cosmos,  so  out  of  this  soiu'ce  there  now  arise 
falsifications  of  the  enwonment. 

"  We  have  been  tracing  in  these  mental  operations  the  transformation 
of  the  euAdronment  to  the  ahen's  mind :  out  of  the  old  tissue,  by  a  species 
of  rearrangement  and  reconstruction,  is  woven  a  fabric  representing  to 
him  the  reahty  of  external  things,  and  which  to  him  is  the  only  reality, 
but  to  his  former  state  of  sanity  is  an  utter  falsification.  Since  the 
morbid  eoncej)t  is  projected  out  as  the  actual  cosmos,  and  since  internal 
order  must  correspond  to  the  external,  so  a  transformation  of  the  ego 
itself  resjDonds  to  this  altered  state — the  former  identity  is  lost  and  re- 
placed by  the  new. 

"  And  here  we  have  an  explication  of  that  newly  acquired  freedom 
which,  at  this  juncture,  aj)pears  to  dawn  upon  the  mind  of  the  monoma- 
niac. No  longer  are  phenomena  in  the  outer  world  laboriously  investi- 
gated and  subordinated  to  rigid  laws  of  logic  and  of  science — they  pass, 
as  through  a  magic  crucible,  the  morbid  tissue  of  his  brain,  and  are  trans- 
formed in  accordance  with  no  objective  laws,  but  take  their  color  wholly 
from  the  morbid  emotional  states  present.  Self-creations  arise  with 
wondrous  celerity  and  of  protean  form ;  and  the  morbid  imagination  con- 
jures up  fantastic  groupings  utterly  devoid  of  coherence  and  objective 
reality.  A  feeling  of  new  freedom  replaces  the  old  one  of  restriction  and 
aggression  by  the  en^dronment,  and  the  ego  is  consequently  endowed 
with  new  faculties,  new  powers — becomes  a  mighty  potentate  or  a  god. 
Still  the  environment  is  indelibly  stamped  ^x^\l  the  malign  character 
which  the  former  emotional  state  fostered,  and  it  is  only  in  late  stages  of 
the  malady  that  such  realization  of  a  new-got  freedom  entirely  effaces 
the  enmity  of  the  non-ego  from  the  mind." 

The  importance  of  delusion  as  a  symptom  of  insanity  cannot  lie  too 
strongly  held.  It  is  the  most  conspicuous  and  least  easily  misunderstood 
embodiment  of  intellectual  perversion,  and  therefore  has  been  the  strong- 
est element  in  the  formation  of  medico-legal  tests.  There  are  few  defi- 
nite insanities  in  which  at  some  time  or  another  it  is  not  manifest,  and 
it  always  involves  the  distortion  or  unconsciousness  of  self.  All  other 
sorts  of  aberrations  enter  in  its  production,  and  it  is  active  and  retro- 
active ;  and  it  is  only  when  the  power  to  recall  concepts  is  destroyed  that 
this  impression  of  insanity  is  absent. 

Insane  delusions  are,  as  a  rule,  strengthened  by  false  adductions  of 
proof — the  natural  result  of  a  disordered  perception  ;  and  their  tendency 


JXSJXITY  IX  ITS   MEDirO-LECAL    liKAIilXG.S.  41 

is  to  l)e(!()iiie  more  and  more  inisysteniatized.  Trivial  and  oftentimes 
absurd  liappenings  will  be  seized  upon  by  the  patient  and  dig'nilied  to 
tlie  positi(m  of  corroborative  proof.  No  better  example  of  Mliat  I  have 
said  can  he  presented  than  the  case  of  a  patient  Avho,  while  insane,  came 
from  Chicafi-o  to  New  Yoi-k  l)y  rail,  and  whose  journal  thus  gTaphically 
reproduces  her  insajie  hallucinations,  illusions,  and  delusions : 

Extfurt  of  Jonnidl. 

Left,  Chicago  by  tlie  8.15  Gmiul  Trunk  Kaihvay.  falling  ^Irs.  D good-by,  but 

adding  that  I  did  not  mean  to  do  8o  to  the  rest;  that  she  would  hear  from  me  again, 
as  but  for  her  I  wouhl  have  enjoyed  little  rest  at  night — and  so  I  do  mean  to  wi'ite  to 
her.  On  entering  the  car  I  immediately  perceived  one  old  man  and  one  old  Avoman. 
who  coughed  loudly  and  sent  a  meaning,  too,  and  toward  the  man  in  front  of  me,  and 
from  this  conversation  I  gathered  (which  took  place  in  German,  directed  toward  a  fat, 
vulgar  woman  on  the  left)  :  "She  has  got  to  go  through  with  it,  because  we've  got  to 
get  paid.  Have  you  gone  through  the  other  car?"  "No,"  replied  the  woman.  "I'll 
leave  it  to  j'ou  to  work  through  it — that's  all  right."  A  meaning  nod  and  look  of  assent 
was  exchanged  by  the  conductor,  and  a  woman  behind  me  rose  to  look  at  me,  nodded 
assent  to  the  old  man,  who  laughed  and  grinned,  conspieiiously  cleared  his  throat,  as 
much  as  to  say,  "  You've  got  to  pay  us."  In  enters  a  short,  thick-set  man  with  a  black- 
silk  cap.  I  believe  he  is  the  friend  of  the  dark,  tall  man  I  recognized  before  in  Chicago, 
so  I  knew  well  what  to  expect.  About  three  o'clock  at  night  I  heard  a  lady  opposite 
me,  on  a  line  with  me,  say:  "That  lady's  head  must  be  aching — she  has  not  changed 
her  position  from  the  time  she  entered  the  car."  The  man  in  front  of  me,  avIio  carried 
on  the  conversation  before  in  German  to  the  woman,  said  (he  was  not  the  same  man 
who  sat  there  fir.'it  when  I  entered  the  ear) :  "You  see,  they're  on  the  lookout.  We'll 
get  so  and  so  to  stand  in  front  of  her  so  sho  can't  see  her,  and  a  string  of  them  to  pass 
from  the  next  car,  and  that'll  make  it  all  right."  And  true  enough  a  i>rocession  passed, 
each  nodding  assent,  and  the  old  man  conspicuously  again  cleared  his  throat.  I  got 
up  then  and  asked  the  lady  who  had  mentioned  almost  my  not  stirring  to  sit  with  her, 
told  her  the  conversation  I  overheard,  and  as  I  was  traveling  alone  I  should  be  so 
much  o1>liged  to  sit  with  her  Tintil  she  left  the  car,  to  which  she  kindly  assented.  The 
car  was  filled  Avith  a  low  lot  of  German  emigrants  and  detectives  I  had  recognized 
from  Chicago.  Near  Hamilton  I  overheard  one  say,  "  She's  paid  her ;  now  she  must 
share  with  us."     When  we  left  Hamilton  I  asked  a  nice,  kind-looking  lady  from  Little 

Falls,  Mrs.  L ,  permission  to  sit  with  her ;  she  was  so  kind,  thanks  to  her.     Kude 

glances  and  smacks.  Even  while  talking  to  her,  a  woman  deliberately  knocked  me.  and 
on  entering  the  car  at  Suspension  Bridge  it  took  all  of  my  agility  to  evade  a  premedi- 
tated encounter  from  a  man  with  a  gray  overcoat.  A  charming  lady  dressed  in  mourn- 
ing entered  the  car,  and  I  did  enjoy  my  talk  with  her — so  refreshing  after  the  hard 
crowd  I  had  been  thrown  with — and  was  so  sorry  when  we  parted  in  Buffalo,  where  I 
took  the  buss  and  changed  for  New  York  Central.  As  I  waited  at  the  station  I  asked 
the  nicest-looking  lady  in  the  waiting-room  to  sit  with  her  until  she  reached  New  York, 
and  she  readily  assented ;  but  I  changed  my  mind,  for,  to  my  horror,  I  saw  that  same 
detective  of  Chicago  with  the  black  cap  say  to  her  that  he  had  his  bet  on,  "and  you 
must  share  with  us ;  she's  paid  the  others,  and  she  will  you ;"'  and  a  nod  of  assent  fol- 
lowed, and  a  quieting  inHueiice  sjiread  over  all  the  German  emigrants  who  had  accom- 
panied me  from  Chicago,  and  the  vulgar  woman  and  the  Avife  of  the  old  man  said,  ••  Of 
course  she's  got  to  pay — we'll  niak-c  her ;  Ave'U  run  her  out  of  New  York,  just  as  they 
did  out  of  Chicago ;  irv  work  that  game  better  than  they  do :  Ave've  got  some  of  their 
own  men  on  our  side.''  So,  seeing  a  nice-looking  lady  behind  me  Avith  a  dog.  I  de- 
termined upon  taking  a  palace- car,  paying  for  my  sleeper,  but  sitting  in  it,  and  fol- 
loAved  the  nice-looking  lady  in  the  palace-car,  Avho  Avas  followed  by  an  old  gentleman 
who  crossly  insisted  upon  keeping  her  dog.  The  old  gentleman  left  her  and  a  dashy- 
looking  one  gave  her  a  note  to  read  in  the  car,  sat  by  her.  When  he  left  I  joined  her. 
but  I  perceived  after  talking  to  her  aAvhile  a  marked  reserve  and  coolness  Avhich  I  had 
not  observed  before  she  spoke  to  the  man.  On  the  contrary;  and  her  eyes  Avere  fixed 
toAvard  a  man,  as  seA'eral  at  the  back  of  us,  and  I  saAv  a  forced  manner  in  her  toAvard 
me  Avas  the  result,  and  I  understood,  by  a  glance  to  the  man  in  a  line  Avith  us.  that 
they  had  struck  a  bargain.  The  porter  came,  and  I  told  him  I  Avished  to  sit  up  all 
night,  and  I  Avould  pay  him  for  my  berth,  as  I  did  not  Avish  to  enter  the  car  Avith  the 


42  ^   SYSTEM  OF  LEGAL^ MEDICIXE. 

low  German  emigi-ants.  He  said,  "All  the  berths  are  taken."  "Well,"  I  said,  "then 
find  nie  a  seat  in  another  ear."  "  Well,"  was  his  rejjly,  "Ave'll  sfe  what  we  can  do  for 
3"ou,"  and  off  he  went.  The  man  on  a  line  calls  him  :  "  Plere  are  fi^-e  dollars  for  you  !  " 
"Yes,  sir."  The  gentleman  raised  his  finger:  "Now  you  stick  to  it,"  and  a  nod  of 
assent.  Up  he  comes  to  me  and  asks  for  my  ticket.  I  give  it  to  him  out  of  the  bag, 
and  instead  of  his  retui'ning  it  into  my  outstretched  hand  he  puts  it  in  vay  lap.  Tlie 
nod  previous  had  made  me  suspicious  of  him,  and  1  thought  of  asking  the  lady  to  take 
the  ticket,  but  thought,  "Surely  she  will  think  me  crank}-,"  and  picked  it  up,  and  at 
once  .s-cnf  the  nod  of  assent  on  the  lad)^  opposite  directed  toward  the  gentleman  who  had 
jjaid  the  man  the  five  dollars,  and  looking  at  him;  he  meant,  "  JS'oiv  you  can  say  you 
saw  her  do  it,  and  una-  /understand  the  whole  business."  The  lady  got  up  and  changed 
her  seat,  and  the  jjorter,  in  an  insinuating  way,  at  once  joined  me,  and  said  he  could* 
give  me  a  berth  above  the  lady.  I  told  him  I  did  not  wish  one,  and  at  once  got  up 
and  joined  the  lady  on  the  other  side.  He  followed  me  and  said,  "I  can  let  you  sit 
up,  if  you  wish,  down  there,  but  it  will  cost  you  seven  dollars."  At  once  I  saw  tlirough 
the  whole  btisiness.  He  wished  my  seven  dollars  to  cover  the  man's  five  dollars  to 
whom  he  winked,  so  I  firmly  said  I  had  no  idea  of  paying  that — to  take  me  to  the  other 
■ear  at  once ;  and  so  I  left,  and  he  put  me  among  the  Gierman  emigrants,  saying  I  was 
"  crazy."  The  fact  is,  he  Avas  mad  I  had  fooled  them,  and  though  I  knew  I  would  have 
a  rough  time  of  it,  I  determined  to  jalace  myself  in  God's  hands.  After  finding  out  the 
lady  who  first  spoke  to  me  in  the  waiting-room  I  asked  her  to  be  with  me  until  we 
reached  New  York,  and  I  took  the  end  seat  in  the  car,  which  was  very  uncomfortable. 
After  a  while  a  string  of  men  jjassed,  just  as  they  did  when  I  left  Chicago.  The  man 
cleared  his  throat,  all  nodded  in  procession,  and  a  low  fellow  in  an  impudent  manner 
reclined  on  the  side  seat.  I  immediatelj^  changed  mine,  and  asked  to  occupy  the  one 
facing  the  lady,  to  which  she  assented.  Immediately  the  man  with  the  cap  came  up 
and  said  something  very  earnestly  to  her  I  could  not  hear.  She  got  up ;  a  string — 
three — of  men  closed  in  upon  me,  and  looked  awful  nasty  and  vulgar.  I  closed  my 
eyes.  The  same  performance  took  place  in  the  night  several  times  in  the  presence  of 
the  lady,  who  told  me  she  left  in  the  Weisland ;  and  my  only  salvation  was  in  turning 
around,  closing  my  eyes,  and  saying,  "  Now  I  lay  me  down  to  sleep."  What  else  could 
I  do?  Who  else  could  help  me?  Toward  6  a.m.  the  vulgar  woman  said  in  German, 
"I  trap  geld" — it  means  fine,  pay  for  punishment.  Of  coitrse  I  pricked  up  my  ears. 
"  We's  got  her,"  said  another.  "  Now  we'll  liave  her  up  and  make  her  pay ;"  and  I  saw 
two  grim-looking  men  opi^osite  me.  They  looked  like  farmers,  very  fierce.  I  thought 
to  myself,  "I'd  like  to  sec  you  dare  lay  youi-  hands  upon  me;  I'd  make  it  hot  for  some 
of  you  rascals." 

The  manifestation  of  delusions,  of  coui'se,  bears  a  direct  relation  to 
the  particular  form  of  insanity,  and  their  development  is  largel}^  depend- 
ent upon  the  habits  of  life,  environineut,  and  cause  of  the  mental  dis- 
ease, as  well  as  the  emotional  activity  at  the  time.  There  ai-e  depressed, 
expansive,  grandiose,  erotic,  religious,  and  hypochondriacal  delusions, 
the  latter  being  chiefly  suljjective,  i.e.,  sensorial.  They  vary  from  time 
to  time,  are  subject  to  many  influences,  and  are  more  or  less  tenaciously 
held.  What  is  known  as  a  fixed  delusion  is  one  of  a  dominant  charac- 
ter, which  is  obstiuately  entertained  and  rarely  changed  in  any  way, 
and  forming  the  conspicuous  symptom  of  the  insanity. 

"VMiat  are  known  as  concealed  delusions  are  those  which  are  sup- 
pressed, tlie  luiuxtic  preserving,  when  occasion  requires,  so  much  self-con- 
trol that  it  is  impossible  to  extort  from  him  liis  insane  false  belief ,  which, 
however,  at  other  times  he  expresses  very  freely.  It  is  very  common,  as 
I  liave  said,  for  people  with  limited  delusions  to  present  little  or  nothing 
wliich  draws  attention  to  their  real  condition,  such  subjects  being  gen- 
erally well  behaved.  These  are  the  cases  that  lead  to  controversies  in 
court  and  often  end  in  the  discomfiture  of  the  physician.  With  free- 
dom in  vieAV,  the  clever  lunatic  can  T)e  so  aroused  and  on  the  alert  as 
to  deceive  every  one  about  him,  and  he  is  trium}>liantly  discharged  as 
an  injured  person.     I  can  recall  many  instances  of  this  kind  which  are 


JX.SJXITY  IX  ITS   MKDlCO-LKdAL   liKAIUXdS.  43 

more  or  less  dramatic,  and  one  in  ])articular  whei-e  llie  delusion  was  of  a 
re]i<j;ious  eliaracter,  and  thoug'li  it  was  referred  to  a^  dozen  times  a  day 
l)y  the  patient  while  in  the  asylum,  it  was  found  utterly  irn])ossil)le  to 
tivt  him  in  court  to  give  any  indication  of  his  disease.  Finally,  after  the 
man  had  undergone  a  trying  and  perfectly  satisfactory  examination  in 
regard  to  his  business  capacity  and  ability  to  take  care  of  hiinself  in 
ordinary  ways,  he  was  asked  by  the  lawyer  for  the  defense  the  question, 
''Who  are  you?"  and  replied  almost  immediately,  his  numner  changing- 
to  one  of  excitement,  "  I  am  the  Lord  Jesus  C'hrist."  It  was  subsequently 
easy  to  convince  the  jury  that  he  had,  as  a  result  of  this  delusion,  in- 
ilidged  in  threats  which  inqjlied  a  use  of  his  great  inuiginary  ])e7'soual 
power,  and  he  was  returned  to  the  care  of  his  custodians.  Anotlier  case 
of  the  kind  nuiy  be  cited  as  an  illustration — that  of  a  small  merchant 
who  inherited  a  moderate  competence.  He  had  been  ujoro  or  less  iden- 
tified with  local  charities  and  church  affairs,  but  the  accession  of  the  new 
fortune  proved  too  much  for  him,  and,  with  other  symptoms,  he  speedil_Y 
derived  the  idea  that  he  was  a  great  reformer,  aiul  ])roceeded  to  put  his 
theories  in  practice.  He  liired  a  floor  in  the  Bowery,  and  invited  the 
half-grown  bo3's  and  girls  of  that  questionable  locality  to  make  the  rooms 
their  headquarters  and  trysting-place.  While  his  relations  with  them 
were  exceedingly  questionable  for  a  long  time,  it  was  not  until  the  dis- 
appearance of  clothes  from  the  lines  of  the  neighboring  tenement-houses, 
and  the  noise  and  disorder,  that  the  attention  of  the  police  was  attracted 
and  the  place  was  raided.  After  his  arrest,  his  family,  recognizing  the 
change  in  his  mental  condition,  had  him  examined  by  two  physicians, 
who  committed  him  to  an  asylum ;  but  through  the  efforts  of  a  specu- 
lative lawyer  a  hal)eas  corpus  was  procured  and  he  was  l)rought  Ijefore 
the  sheriff's  jury.  A  long  examination,  which  was  chiefly  directed  to 
show  his  a])ility  to  execute  business  papers,  compute  interest,  and  to 
disavow  that  he  was  insane,  resulted  in  his  discharge,  with  a  word  or 
two  of  censure  for  the  doctors.  He,  however,  of  his  own  volition  went 
back  to  the  asylum,  where  he  stayed  despite  the  efforts  of  the  superin- 
tendent to  get  rid  of  him,  and  his  behavior  was  clearly  that  of  a  luimtic, 
his  delusions  being  freely  expressed.  He  threatened  to  sue  the  physi- 
cians who  committed  him  ludess  they  gave  him  the  opportunity  to 
deliver  his  peculiar  address  before  one  or  more  medical  l>odies.  I  exam- 
ined him  and  found  the  well-marked  synq)toms  of  early  paretic  dementia. 
He  had  delusions  of  power,  and  a  confidence  in  his  own  Cii])a1)ility 
as  a  reformer  that  was  refreshing.  His  theory  in  regard  to  the  immac- 
ulate conception  was  that  it  was  through  a  kiss,  and  he  proposed  to  do 
away  with  the  ordinary  method  of  intercourse  and  substitute  a  ])lan  of 
his  own  which  was  in  every  way  to  be  more  pure.  The  patient  was 
liberated  upon  application  of  a  lawyer  who  was  one  of  the  strongest 
agitators  in  the  mov(Mnent  which  was  directed  to  open  the  doors  of 
lunatic  asylums,  and  his  interest  in  his  client  was  very  great.  He,  how- 
ever, received  a  rude  check  when  he  presented  his  bill  for  professional 
services  and  the  client  procecnled  to  issue  l)t)nds  and  })ank-notes  for  its 
liayment,  Avhicli  he  made  with  a  pen  and  whatever  scraps  of  paper  he 
eould  lay  his  hands  upon.     This  man  has  since  committed  suicide. 

Instances  of  this  kind  could  be  multii)lied.  and  these  two  examples 
are  brought  forward  to  show  how  easy  it  is  to  be  mistaken,  and  to  direct 
the  attention  of  judges  and  jurors  to  the  necessity  for  prolonged  Avateli- 


44  ^   SYSTEM  OF  LEGAL  MEDICINE. 

ing  and  tlie  applicatiou  of  tests  which  must  be  more  satisfactoiy  than 
those  ordinarily  employed.  Spitzka  calls  attention  to  the  fact  that  the 
possessor  of  those  systematized  delusions  which  relate  to  social  and  polit- 
ical ambition,  as  a  rule,  jDOSsesses  a  higher  intellectual  activity  than  the 
holder  of  erotic  and  religious  insane  falsv?  beliefs.  It  is  certain  that  the 
former,  who  are  ver^-  numerous  and  usually  behave  themselves,  comjiar- 
atively,  so  well  that  thej^  keep  outside  of  the  walls  of  the  asylums,  are 
often  simply  recognized  as  "  cranks." 

The  erotic  and  religious  delusions  are  more  apt  to  be  manifested  by 
the  possessors  of  acquired  acute  insanity.  Systematized  erotic  and  relig- 
ious delusions  are  apt  to  be  entertained  by  the  same  person,  and  spring 
more  or  less  from  each  other.  The  erotic  belief  is  often  pure  and  has 
relation  to  abstract  things,  and  is  not  connected  with  emotional  excite- 
ment of  a  physical  kind,  though  its  genesis  m.ay  dej)end  ujdou  a  local  irri- 
tation, mth  indulo-euce  in  mastm'bation. 


INSISTENT   AND   DIPERATIVE   CONCEPTS. 

Insistent  and  imperative  concepts  mark  a  species  of  mental  weak- 
ness in  which  the  xjatient's  conduct  is  more  or  less  strongly  influenced^ 
he  often  being  able  to  realize  the  domination  of  his  affection.  Some- 
times this  realization  is  lost  and  the  morbid  impulses  gain  possession,  so 
that  in  a  condition  of  high  tension  he  commits  some  act  which  is  followed 
by  subsequent  repentance  and  distress.  A  number  of  names  have  been 
applied  to  forms  of  mental  disease  of  this  kind,  and  they  extend  from 
the  lower  form,  which  maybe  called  doubting  insanity,  or  Gruhelsucht,  to 
serious  reasoning  and  impulsive  insanity.  The  impulse  which  one  feels 
when  tempted  to  jump  from  a  height,  or  to  use  some  dangerous  weapon 
that  may  be  at  hand,  is  an  instance  of  an  imperative  concept  of  a  low 
order.  Certain  insane  acts  may  lead  to  the  commission  of  others  by 
patients  of  this  kind  with  imitative  tendencies,  and  this  explains  the  eiji- 
demics  of  crime  which  occasionally  occur  whenever  some  j)articularh^ 
dramatic  or  "vWdely  advertised  horrible  "  sensation "  has  taken  place. 
Under  this  head  we  find  the  crimes  of  instinctive  ci'iminals  whose  dis- 
order is  manifested  in  such  as  kleiDtomania,  pyromania,  and  other  im- 
pulsive forms  of  derangement,  in  which  the  dominant  concept  produces 
a  physical  impression,  etc.,  which  is  manifested  in  the  exercise  of  ex- 
plosive motor  acti\dty,  the  offense  against  society  possibly  being  the 
cidmination  of  months  or  j^ears  of  temptation  and  resistance,  and  pre- 
ceding well-developed  and  conspicuous  insanity  which  has  j)assed  the 
bounds  of  inhibition. 

The  dominance  of  the  concept  is  rather  constant,  and  is  governed  l)y 
the  patient's  surroundings  and  occupation.  To  the  same  extent  its  influ- 
ence maj'-  be  antagonized  b}^  persistent  exercise  of  will-power,  by  diver- 
sion and  change  in  the  mode  of  life.  Intense  concentration  in  one 
direction  is  ax)t  to  lead  to  the  morbid  exercise  of  activity  and  a  frequent 
irritation  and  limited  stimulation  of  ideational  centers.  The  imperative 
concept  may  arise  suddenly  and  without  relation  to  the  particular  line  of 
thought,  being  displayed  in  some  erratic  liehavior.  Where  it  exists 
there  is  nearly  always  inlK^ited  weakness,  and  often  a  remote  history  of 
alcoholism  or  epilej)sy.     The  hysterical  w(nnan  is  more  subject  to  this 


IXSJ^^ITY  IN  ITS  MEDICO-LEGAL   BEAliiyOS.  45 

foi'iii  of  mcMital  disorder  than  tlic  male,  as  slie  is  in  many  ways  more 
snbject  to  ideational  activity  than  the  latter.  There  may  be  a  (^onditioii 
whieli  is  almost  aiitomatie,  the  vxn\vA'\)i  Ix'in*^'  repeated  over  and  over, 
and  (^uite  beyond  the  control  of  other  inlii])itory  or  restraining  influences. 
So  far  as  its  connection  with  special  forms  of  disease  is  concerned,  we 
iind  that  it  is  present,  as  a  rule,  in  the  depressed  forms  of  insanity,  as 
well  as  insanities  with  limited  delusions,  paranoia  being  an  instance. 

Cases  of  suicidal  and  homicidal  insanity,  where  the  act  is  the  result 
of  so-called  morbid  impulse,  are  explained  by  the  presence  of  dominant 
imperative  concepts.  Like  delusions,  these  persistent  concepts  are  often 
concealed  by  the  patient,  who  surprises  her  friends  or  the  community 
by  some  unlooked-for  act ;  and  my  note-books  contain  numerous  observa- 
tions where  people  have  thrown  themselves  from  windows,  or  attempted 
suicide  in  one  way  or  another,  not  having  displayed  beforehand  any  con- 
spicuous failure  of  mental  health.  Very  often  the  explosion  or  giving 
way  is  followed  by  a  reaction  and  a  subsidence  in  the  patient's  insanity, 
at  least  for  a  time.  Persistent  concepts  are  likely  to  lead  to  the  forma- 
tion of  delusions,  especially  when  no  moral  treatment  is  suggested.  It 
may  be  stated  that  many  of  the  cases  of  so-called  moral  insanity  are, 
after  all,  nothing  but  a  disorder  characterized  by  imperative  and  insist- 
ent concepts. 

A  number  of  terms  have  been  applied  by  writers  to  the  above-men- 
tioned forms  of  mental  degeneration,  where  the  conduct  of  the  patient 
was  determined  by  the  existence  of  one  kind  of  dominating  concept  and 
the  more  familiar  forms  of  doubting  insanity.  These  consist  in  the  fear 
of  open  spaces — agoraphobia ;  fear  of  the  stars ;  claustrophobia  ;  fear  of 
contamination;  imperative  impulse  to  count,  to  touch,  etc.  An  illustra- 
tive case  of  much  interest  may  be  presented  : 

The  patient  was  a  man  of  thirty-five,  presenting  the  stigmata  of 
defective  evolution.  He  was  markedly  dolichocephalic,  his  teeth  were 
irregular,  his  forehead  retreating,  and  his  muscular  motility  impaii-ed. 
His  family  history  was  essentially  neurotic.  His  mother,  after  a  life 
passed  as  an  extreme  fanatic,  ended  her  daj^s  in  a  lunatic  as^ylum.  His 
father  drank  immoderately  and  died  in  an  asjdum.  One  of  his  brothers 
was  intemperate,  and  his  sister  was  hysteric  and  neurasthenic,  while  one 
of  his  maternal  uncles  was  also  a  drunkard.  He  had  for  several  years 
been  a  prominent  figure  in  the  town  in  which  he  lived,  and  had  devoted 
himself  to  prohibition,  his  enthusiasm  being  expressed  in  constant  litiga- 
tion and  self-glorification.  His  entire  life  had  been  modeled  upon  plans 
laid  down  by  social  reformers  whose  teachings  were  bad,  and  marriage 
guides  and  books  upon  domestic  medicine  played  a  great  part  in  shaping 
his  home  life.  In  spite  of  his  peculiarities  he  is  a  successful  business 
man,  and  has  saved  enough  to  live  in  comfort  without  helping  liis 
brothers,  who  are  his  partners,  in  the  management  of  their  business. 
His  manner  at  the  time  of  his  visit  was  very  hesitating  and  full  of  inde- 
cision. There  was  much  hesitation  in  telling  his  story,  and  in  answei'ing 
my  questions  he  repeated  himself  frequently.  He  fully  appreciated  his 
mental  state,  and  suffered  very  great  agony  of  mind  and  want  of  faith  in 
himself.  His  active  mental  unsoundness  had  lasted  for  several  years,  and 
began  hy  a  gradual  fear  of  defilement  from  contamination.  It  was  rear 
sonable  enough  at  first,  and  simply  followed  acts  that  naturally  required 
subsequent  resort  to  soap  and  water.     But  this  increased  so  that  he  now 


46  ^   SYSTEM  OF  LEGAL  ALEDLCLXE. 

washes  liis  hands  from  tliii't^'  to  forty  times  daily,  aud  always  does  so 
after  haudliug  money.  The  impulses  that  eomjiel  him  to  calculate  are 
shown  almost  entirely  in  business  matters,  althougii  his  habit  is  now  to 
weigh  all  coin  that  he  receives  or  gives  out,  and  this  he  has  done  for  the 
past  two  years.  The  question  of  the  honesty  of  others  does  not  seem  to 
figure  lai-gely  in  this  procedure,  for  he  weighs  the  money  which  he  gives 
to  them  and  counts  the  l)ills  repeatedly,  often  following  the  recipient 
several  times  in  the  day  to  know  whether  the  amount  he  has  paid  is 
correct.  He  carries  scales  with  him,  not  daiing  to  ti'ust  himself  without 
them,  and  while  admitting  the  irksomeness  of  his  bondage,  suffers  in- 
tensely if  he  forces  himself  to  place  them  beyond  Ms  reach.  In  his 
efforts  to  escape  the  imperative  impulse  he  often  asks  his  brothers  to 
take  charge  of  his  business,  and  he  has  finally  been  obliged  to  leave 
ever^i:hing  in  their  hands. 

Some  time  ago  his  imperative  concepts  took  another  form,  which 
consisted  in  the  behef  that  ijaper,  pieces  of  tin,  scraps  of  h'on.  on  the 
sidewalk,  street,  or  elsewhere,  would  do  injury  for  which  he  would  be 
morally,  if  not  legally,  responsible  if  he  did  not  remove  them.  Paper 
upon  the  road  that  might  frighten  horses,  scrap-tin  that  might  wound 
them,  loose  cobljlestones,  and  other  objects,  he  woidd  constantly  gather 
and  imt  out  of  harm's  way.  He  was  so  dominated  by  his  morbid  fears 
and  the  possible  consequences  of  neglect  upon  his  part  that  he  refused 
to  sell  nails  to  his  customers  without  remo^T-Ug  the  splints,  and  if  the 
nuts  upon  the  bolts  he  sold  were  loose  he  would  screw  them  up.  He 
Avould  question  2:)m'chasers  as  to  the  possible  harm  that  might  have 
occuiTed,  and  upon  one  occasion,  when  he  went  to  Long  Branch  for  his 
vacation,  after  an  hour  of  anxiety  and  doubt  upon  the  steamboat,  he 
turned  back  at  Sandy  Hook,  to  remove  a  banana-skin  he  had  passed 
without  picking  up  on  the  sidewalk  in  New  York.  His  morbid  fears 
were  excited  by  any  object  which  might  do  hann.  matches,  combustibles, 
and  shai-p  tools  Ijeing  included,  and  he  was  finally  ol:>liged  to  seek  new 
emplo^-ment,  taking  charge  of  the  bill-collecting  part  of  the  business. 
There  was  not  in  his  case,  anything  that  might  be  regarded  as  a  delu- 
sion. His  relations  with  every  one  except  the  hquor-dealers  were  pleasant. 
He  slept  well,  as  a  rule,  and  suffered  from  insomnia  and  disturl)ed  diges- 
tion only  when  he  undei-went  a  pecuharly  distressing  period  of  doubt. 


AFFECTIONS   OF  ]MEMORY. 

An  impaii'ment  of  memory  is  an  exceedingly  common  s^^nptom  of 
mental  disease.  It  may  consist  in  feeble  receptivity — a  condition  of 
which  imphes  something  more  than  a  failure  of  attention — which  prevents 
the  concept  from  retaining  its  place  in  the  brain :  or  it  is  due  to  a  convolu- 
tional  condition  where  the  mental  impressions  are  light  or  fugacious ;  or  it 
may  arise  from  an  ej^ileptic  cf^)ndition,  with  tempoi-ary  abolition  of  con- 
sciousness :  or  in  a  gi-aver  form  it  signals  a  species  of  involutional  degen- 
eration which  follows  or  attains  the  actual  destiiiction  of  the  cells  of  the 
cerebral  cortex.  It  is  the  all-important  s^miptom  in  dementia,  and  most 
of  the  disorderly  expressions  of  that  condition  are  directly  traceable  to 
mental  disor<rai)ization.  Not  only  may  a  stage  be  reached  where  the 
individual  stops  stoiing  up  the  freshly  recei^-ed  impressions,  but  ulti- 


INSANITY  IN  l'J\S  M/:d1  CO-LEGAL  BEARINGS.  47 

matc'ly  all  tlic  concepts  of  previous  periods  are  lost.  It  is  distinct  from 
congenital  weakness,  which  is  manifested  in  amentia,  where  perceptions 
are  never  attended  by  lasting  concepts,  the  apparatns  of  reception  and 
appropriation  being  nndeveloped. 

Loss  of  memory  nsnally  begins  first  in  the  direction  of  forgetfulness 
of  snbstantives  and  })r()per  names.  "  This,"  says  James  {rsi/rholof/!/,  vol. 
1.,  p.  G83),  ''seems  dne  to  the  fact  that  connnon  (pialities  and  names  have 
contracted  an  infinitely  greater  nmnber  of  associations  in  onr  minds  than 
the  names  of  most  of  the  persons  whom  we  know.  Their  memory  is 
better  organized.  Proper  names  as  well  oi'ganized  as  those  of  onr  family 
and  friends  are  recollected  as  well  as  those  of  any  other  ol)jects.  '  Organ- 
ization '  means  nnmerons  associations ;  and  the  more  nnmerons  the  asso- 
ciations, the  greater  the  nnmber  of  paths  of  recall.  For  the  same  reason 
adjectives,  conjnnctions,  prepositions,  and  the  cardinal  verbs,  those 
words,  in  short,  which  form  the  grammatical  framewoi-k  of  all  onr 
speech,  are  the  very  last  to  decay."  As  Knssmanl  says  :  "  The  concreter 
a  conception  is,  the  sooner  is  its  name  forgotten.  This  is  becanse  onr 
ideas  of  persons  and  things  are  less  strongly  bonnd  np  with  their  names 
than  with  snch  abstractions  as  their  bnsiness,  their  circnmstances,  and 
their  qnalities."  One  of  the  primary  indications  of  mental  impairment 
is  the  inability  to  renew  impressions  and  to  recognize  their  significance, 
to  arrange  them  and  to  apply  them  to  events  and  things ;  and  for  this 
pnrpose,  of  course,  conscionsness  is  essential.  There  is  a  form  of  cerebral 
activity  which  consists  in  the  voluntary  bii'th  of  ideas  that  foi'ce  them- 
selves to  the  surface  without  any  effort,  such  a  process  being  often  in- 
stinctive. 

For  the  estimation  of  how  far  the  memory  is  affected  in  mental  dis- 
ease we  must  fii'st  test  the  patient's  ability  to  recall  concepts  and  to  fix 
their  importance,  to  group  the  ideas  and  to  applj^  them  to  himself,  and 
then  determine  his  ability  to  bring  forward  details  of  the  past,  determine 
his  power  of  time,  localization,  and  perception,  and  incidentally  his  idea 
■of  space.  With  the  enfeeblenient  of  memory  we  find  a  certain  degree  of 
superficial  adjustment  which  the  patient  uses  to  adapt  himself  to  his 
surroundings,  and  which  is  the  result  of  his  desire  not  to  appear  ditt'erent 
^from  others.  Of  course  at  a  later  stage  this  is  lost,  and  the  effort  to 
group  and  arrange  facts  leads  to  incoherence.  What  might  be  called 
the  autonuitism  of  life  is  demonstrated  in  diseases  wdiere  memory  gradu- 
ally fails ;  the  memory  of  recalled  concepts,  lasting  when  others  ai-e  for- 
gotten, showing  that  weak-mindedness  of  this  character,  in  its  insidious 
advance,  is  attended  liy  a  certain  kind  of  ability  upon  the  pnrt  of  the 
patient  to  recall  mental  landmarks  which  he  has  referred  to  habitually. 
:Sometinies  this  apparent  integrity  is  suificient  to  impress  unthinking 
persons. 

The  minor  grades  of  degeneration  are  seen  in  a  familiar  disease 
known  as  aphasia,  Avhich  is  described  elsewhere  ;  but  it  is  proper  for  me 
to  refer  to  the  disturbance  of  automatism,  which  is  manifested  in  tricks 
of  speech  which  sometimes  are  functional  disorders,  or,  on  the  other 
hand,  foreshadow  mental  dissolution,  which  is  not  expressed  until  much 
later  by  unmistakalile  symptoms.  These  consist  in  the  trans])osition  or 
substitution  of  syllables,  stuttering,  hesitation,  and  phonetic  peculiarities, 
which  may  or  may  not  betoken  the  coming  of  physical  as  well  as  mental 
breakiua:  down. 


48  A   SYSTEM  OF  LEGAL  MEDICINE. 


DISTURBANCES   OF  VOLITION  AND  EMOTION. 

The  various  affections  of  will  incident  to  mental  disease  may  be  con- 
sidered as  those  of  an  exaggerated  or  active  character  and  those  of  a 
depressed  or  passive  character. 

The  fii'st  comprise  those  which  are  expressed  as  the  dictate  of  an  hallu- 
cination or  delusion,  or  simpl}^  as  an  instinctive  or  pui-ely  impulsive  act^ 
or  as  the  result  of  an  imperative  concept.  To  this  class  belong  the 
peculiar  explosions  of  the  epileptic  and  hysteric  and  maniac.  The  "^do- 
lent  acts  of  the  former  are  usually  sudden,  attended  by  apparent  un- 
consciousness, and  are  not  remembered  afterward.  Sometimes  the  patient 
while  in  a  precursory  attack  runs  amuck,  stabbing  or  otherwise  assaulting 
those  he  may  by  chance  meet.  The  outbreak  is  paroxysmal  and  the 
assault  j)urj)oseless. 

The  impulses  of  the  insane  find  expression  in  other  ways :  in  destruc- 
tiveness,  self -mutilation,  suicide,  inordinate  consumption  of  food,  the  tak- 
ing of  improper  things  into  the  stomach,  perverted  sexual  acts,  etc. 

It  is  no  uncommon  thing  to  find  women  with  hysterical  insanity  or 
acute  mania  tearing  their  clothing  or  destroj-ing  various  objects.  Some- 
times the  insanity  of  a  patient  whose  condition  has  not  attracted  atten- 
tion is  for  the  first  time  expressed  in  an  imi3ulse  to  destroy  frail  articles. 
This  symptom  is  most  often  present  in  mania  and  does  not  seem  to  be 
the  result  of  delusion  or  hallucination,  but  is  clearly  an  expression  of 
continued  and  intense  excitement.  Various  lunatics,  under  the  force  of 
dominant  concepts,  are  likely  to  commit  a  destructive  act  of  one  kind 
whenever  they  get  an  oj)j)ortunity.  What  are  known  as  piquers  in 
France  are  subjects  of  this  class.  Some  of  them  cut  and  slash  the 
dresses  of  women,  or  poui'  vitriol  or  corrosive  fluids  thereon,  while  others- 
surreptitiously  clip  off  the  haii*  of  young  giiis  in  the  streets.  This  form 
of  imperative  concept  is  likely  to  go  with  sexual  perversion. 

The  chronic  epileptic  is  quite  likely  to  commit  purposeless  acts  of 
destructive  mischief — setting  fii-e  to  buildings  or  -^dlltully  destropng- 
property  with  apparently  no  object  in  view.  At  other  times  the  impulse 
is  to  brutally  murder  some  one.  When  arson  is  committed  it  is  appar- 
ently motiveless,  although  the  insane  love  of  fii'e  or  a  desu*e  for  notoriety 
may  instigate  the  act.  Often  the  crime  is  repeated,  and  in  one  case  that 
occurs  to  me  the  person,  who  was  subsequently  apprehended  and  tried, 
was  clearly  dominated  by  an  imperative  concept.  Self-mutilation  or  the 
mutilation  of  others  is  frequent.  In  the  former  case  it  is  sometimes  sug- 
gested by  an  insane  delusion,  and  the  desire  to  commit  a  sacrifice  may 
be  apparent.  Those  who  suffer  from  religious  delusional  insanity  not 
unrarely  cut  off  their  right  hand  or  pluck  out  their  eyes  as  the  result  of 
a  too  literal  interpretation  of  a  scriptm-al  command.  Generally  as  a  re- 
sult of  sexual  perversion  the  insane  person  vn]i  horribly  mutilate  the 
body  of  a  person  lie  has  murdered,  or  sometimes  he  wiU  obtain  a  sexual 
satisfaction  by  wounding  the  genitaha  of  young  women  or  gMs.  This 
is  known  as  sadism,  and  was  first  practiced  by  the  Marquis  de  Sade, 
whose  insane  orgies  led  to  his  apprehension  by  the  French  police.  (Tide 
La  Corruption  fin  de  8iecle,  Leo  Taxtil.) 

Fantastic  and  ingeniously  contrived  suicides  are  often  committed  by 
the  insane,  either  witji  delusional  suggestion  or  impulsively.     The  para- 


IXSJNITY  IX  ITS  MEDICO-LEGAL   liEAlilXGS.  49 

iioiac  not  infrequently  infuses  into  his  takinfif  off  some  element  that 
brings  jjosthumous  notoriety,  and  a  crop  of  imitators  repeat  his  widely 
advertised  death.  Kirehlioff  has  called  attention  to  the  fact  that  the 
impulsive  suicide  of  the  lunatic  nnist  be  disting'uished  from  that  where 
he  jumps  from  the  window  or  into  a  river  to  avoid  an  ima«:inary  danger 
suggested  by  his  hallucinations  or  delusions.  The  suicidal  act  is  some- 
times wholly  inexplicable  except  by  inheritance,  there  l)eing  an  apparent 
l)lind  fatality,  and  no  recognizable  immediate  disturl)anee  of  intellect  to 
•explain  the  self-destruction.  The  writer  has  had  a  family  of  this  kind 
under  observation  for  many  years,  and  no  less  thaji  six  sons  and  daugh- 
ters have  attempted  suicide,  or  have  actually  succeeded  in  destroying 
themselves,  at  various  times.  As  a  rule  the  act  was  committed  between 
the  twentieth  and  thirtieth  years,  and  in  no  instance  was  there  the  least 
apparent  reason  or  motive. 

A  morbid  propensit}'  not  only  for  the  ingestion  of  large  quantities  of 
food,  Ijut  of  foreign  suljstances  as  well,  symptojnatizes  an  impulsive 
insanity,  which  may  or  not  be  connected  with  some  perversion  of  the 
physiological  process  which  regulates  the  appetite.  The  tendency  of 
hysterical  women  to  eat  chalk  or  drink  acids,  the  morbid  desu-e  for  vari- 
ous essential  oils  and  aromatic  substances,  are  minor  indications  of  gus- 
tatory and  oKactory  perversion  connected  with  impulsive  acts ;  but  there 
is  an  insane  longing  for  foul  and  repulsive  suljstances,  which  is  present 
in  the  victims  of  evolutional  as  well  as  acquired  insanity,  which  leads  to 
the  devouring  of  faeces.  Another  form  of  disgusting  impulse  finds  vent 
in  the  eating  of  human  flesh.  The  al)stinence  fr(nn  food  is  usually  the 
result  of  delusion  or  hallucination,  so  that  in  many  asylmns  the  necessity 
for  forced  feeding  arises,  the  patient  refusing  nourishment  because  he 
believes  he  has  been  gifted  "^^dtll  supernatural  powers  of  endurance,  or 
that  he  is  offending  God  by  eating.  In  other  cases  where  sensorial  de- 
lusions exist  the  patient  refuses  food  because  he  declares  his  stomach  or 
intestine  is  tenanted  b}'  some  living  animal.  At  times  refusal  of  food 
■depends  upon  the  fear  of  poisoning,  such  a  delusion  being  one  of  the 
most  frequent  and  important  of  all.  Of  course  real  disorders  of  the 
gastro-enteric  tract  will  lead  to  a  loss  of  appetite. 

Sexual  impulses  of  an  unusual  kind  betoken  the  existence  of  mental 
degeneration.  As  a  rule  such  perversion  and  loss  of  control  belong  to 
the  possessor  of  the  "  insane  diathesis,"  the  victim  of  evolutional  insan- 
ity ;  but  the  general  behavior  of  the  sexual  pervert  need  not  be  conspic- 
uous. Like  the  \'ictim  of  imperative  concepts,  he  is  in  other  ways,  as 
a  rule,  fairlj'  strong  intellectually  although  he  may  l^e  the  possessor  of 
a  congenital  weakness  which  lueans  a  complete  transposal  of  his  normal 
appetites  and  powers.  IMany  indi^^duals  entertain  sexual  longings  only 
for  their  own  sex,  and  such  find  a  form  of  gratification  which  it  is  not 
necessary  to  here  particularize  (see  Dr.  Chaddock's  article).  In  many 
large  cities  the  subjects  of  the  contrary  sexual  impulse  form  a  class  by 
themselves  and  are  recognized  b}^  the  police.  The  men  have  their  balls, 
where  they  dress  as  women  even  to  the  details  of  dainty  underwear.  (Fig. 
12.)  Thej'  adopt  the  names  of  women,  and  affect  a  feminine  speech  and 
manner,  ''falling  in  love"  with  each  other,  and  writing  amatory  and 
obscene  letters.  In  New  York  City  alone  there  are  not  less  than  one 
liundred  of  these,  who  make  a  i>rofession  of  male  prostitution,  soliciting 
upon  the  streets  and  in  parks  when  they  get  the  opportunity.   Physically, 


50  A   SYSTEM  OF  LEGAL   MEDICINE. 

many  of  tliese  men  whom  I  have  examined  present  the  stigmata  of  de- 
generative insanity,  or  else  physically  approach  the  female  t^-pe,  and 
hypo-  and  epispadia,s  are  common.    The  female  pervert  or  Lesbian  rarely 

differs  from  others  of  her  sex, 
j''  "  ^         '~^\      except  that  the  active  agent  is- 

gross,  wears  mannish  attu-e^ 
and  cultivates  masculine  hab- 
its* Other  perverts  enjoy 
sexual  pleasure  only  when 
themselves  subjected  to  phys- 
ical pain  and  degTadation; 
others  derive  enjoyment  solely 
from  toi'turing  the  objects  of 
theii-  passion;  while  others- 
alone  gain  satisfaction  in  act- 
ual contact  with  fetiches  such 
as  women's  shoes  and  other 
articles  of  wear.  In  maniar 
hysteria  and  other  expansive 
forms  of  insanity  with  exag- 
gerated sexual  acti\dty,  self- 
control  is  in  part  or  totally 
lost,  and  we  are  presented 
with  the  conditions  of  nymph- 
omania and  satyriasis,  as  ap- 
plied to  the  female  and  male,, 
which  lead  the  patients  to  in- 
dulge in  reckless  excesses,  in- 
decent and  shameless  proposals,  and  conduct  which  is  a  complete  de- 
parture from  the  normal  state.  A  refined  and  high-bred  woman  \\i]l 
make  advances  to  car-drivers,  porters,  or  servants — black  or  white ; 
while  the  victim  of  satyriasis,  who  perhaps  happens  to  be  a  clergyman  or 
dignified  banker,  "will  expose  his  person  in  public  or  court  the  notice 
of  the  police.  False  accusations  of  improper  assault  are  common  with 
these  people,  and  often  lead  to  unhappy  lawsuits  or  criminal  proceedings. 
The  sexual  excitement,  it  must  be  remembered,  may  be  only  a  local 
prompting  and  have  no  intellectual  participation,  and  each  case  should 
be  investigated  carefully,  with  a  view  to  the  recognition  of  the  person's 
ordinary  mode  of  life,  pre'sdous  behavior,  etc.  As  a  rule  there  are  con- 
comitant sj^mptoms  of  insanity. 

The  conversation  of  young  women  who  suffer  from  hysterical  insan- 
ity is  quite  apt  to  dii-ect  attention  to  the  mental  failure.  For  a  long 
time  before  easily  recognizable  expressions  of  disease  are  detected,  the 
patient  will  constantly  talk  about  subjects  naturally  avoided  by  girls.  One 
of  my  patients,  a  young  person  of  very  pure  mind,  devoted  most  of  her 
time  during  the  early  development  of  her  insanity  to  catechising  a  mar- 
ried sister  about  copulation  and  pregnancy,  and  finally  extended  her  in- 
quiries to  the  other  female  and  male  members  of  the  household.    In  this 

*  The  reader  is  referred  to  Krafft-Ebing's  Pfiyelinpafliia  Sexnalis ;  Taxtil's  La  Cor- 
ri(pUon  Fin  dc  Sicde,  and  various  French  romances,  among  them  Mademoiselle  du  Man- 
j)in  or  Mademoiselle  Giraud  -ma  Femme. 


Fiu.  l:i. -?>Iale  Sexual   IVrvcrt. 


IXSAmTY  IX  ITS  MEDICO-LEGAL   BEAllIXGS.  51 

case,  as  others,  the  interest  hi  reho-ious  affairs  becomes  abnormally  in- 
creased, and  may  or  not  be  accompanied  with  a  sense  of  self-depreciation 
which  eventnally  deepens  into  a  delusion  that  the  "unpardona])le  sin" 
has  been  committed.  Religious  excitement  and  sexual  irritation  are  the 
fruits  of  camp-meeting-s,  revivals,  and  occasions  when  emotional  activity 
is  generated  in  crowds.  It  is  not  difficult  to  find  examples  of  this  ei'e- 
thism  among  the  African  devotees  who  practicic  the  Assouia,  the  der- 
vishes, and  in  other  times  among  the  fingellants.  The  subject  of  so-called 
religious  insanity  is  (pute  apt  to  l)ecome  morbid,  introspective,  seclud- 
ing herself,  mortifying  tlie  tiesli ;  then  she  becomes  exalted,  and  has 
hallucinations  and  delusions  of  a  semi-amorous  or  erotic  nature,  believ- 
ing herself  to  be  the  bride  of  Christ  or  the  agency  of  the  immaculate 
conception. 

Some  diseases  are  manifested  by  exaggeration  of  sexual  vigor,  and 
this  is  marked  in  paretic  dementia,  in  mania  and  excited  forms  of  mental 
disorder.  In  estal)lished  involutional  disease  there  is  a  decay  not  only  of 
the  sexual  appetite,  but  a  shamelessness  and  a  weakness  of  desire  which, 
in  senile  dementia.,  manifests  itself  in  indecent  exposure,  urination  in 
public,  indecent  assaults  upon  children,  and  libidinous  loquaciousness. 

Impaii'ed  or  suspended  volition  characterizes  conditions  which  may 
vary  from  ordinary  feebleness  to  those  which  denote  an  actual  suspen- 
sion of  consciousness.  When  in  a  state  of  hypnosis  or  partial  mental 
inhibition  the  individual  may  be  made  to  perform  certain  suggested  acts, 
he  meanwhile  being  the  subject  of  trance.  Attention  is  suspended  and 
inactive,  and  he  does  not  realize  the  nature  of  his  act  unless  attention  is 
artificially  directed.  How  far  the  ego  and  automatic  sense  of  control 
play  a  part  in  limiting  the  power  of  suggestion  is  a  matter  of  question, 
yet  it  has  been  demonstrated  that  it  is  impossible  to  make  an  ordinarily 
virtuous  person  commit  a  crime. 

The  several  indefinite  conditions  of  semi-consciousness  which  consti- 
tute somnambulism,  sleep-drunkenness,  and  dreaming,  all  imply  a  partial 
inhibition  of  self-cognizance  and  ideation ;  and  the  diminished  exercise 
of  volition  is  the  result  of  some  automatic  process  or  outside  stimulation 
of  subcortical  function.  The  insane  are  apt  to  display  an  atonic  indis- 
position. This  not  only  characterizes  the  apathetic  and  stuporous  vari- 
eties of  melancholia,  but  is  a  feature  of  quiet  dementia.  Fixed  positions 
are  adopted,  muscular  movement  is  slow  and  rarely  made  mtliout  sug- 
gestion, immobility  is  the  rule,  and  at  times  the  muscular  condition  is 
one  of  a  cataleptic  character.  There  need  not  be  the  rigidity  attended  by 
annssthesia  and  loss  of  consciousness,  characteristic  of  catalepsy  pi-oper, 
but  in  connection  with  great  intellectual  torpor  there  is  a  disposition 
for  the  legs  or  arms  to  remain  in  whatever  position  they  may  be  placed. 
Recurrent  attacks  of  this  condition  charactei'ize  a  form  of  insanity 
known  as  hifafoiiia,  in  which  a  primary  melancholia  is  followed  by  an 
excited  delusional  condition,  mth  verbigeration,  secondary  inaction,  and 
muscular  rigidity,  and  termination  in  dementia. 

The  chronic  insane  are  sometimes  exceedingly  indifferent  to  external 
irritations  or  influences,  especially  when  a  condition  of  dementia  has  been 
reached.  This  is  due  not  only  to  the  mental  torpor,  but  to  an  actual 
ana?stliesia.  Burns,  the  contact  of  irritating  substances,  or  the  bites  of 
insects,  provoke  no  impression  and  no  attem]it  at  removal.  This  in- 
difference indicates  a  suspension  or  impairment  of  consciousness  which 


52  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

is  usually  of  slow  duration,  and  divorces  the  patient  from  tlie  rest  of  tlie 
world.  He  is  unable  to  weigh  and  separate  liis  concepts,  or  to  estimate 
and  regulate  their  importance  or  association.  Thev  cannot  be  volunta- 
rily summoned,  and  eventually  it  is  impossible  to  coordinate  internal  im- 
pressions. Self  is  no  longer  recognized,  and  in  the  confusioual  condition 
a  double  j)ersonality  may  perhaps  de"\'elop. 


DEFINITION   AND    CLASSIFICATION. 

The  disorganization  which  results  in  the  inharmonious  operation  of 
mental  function  must  be  considered  as  a  gradual  and  intricate  distiu-b- 
ance  of  psychic  coordination.  The  comparatively  orderly  balancing  and 
expression  of  feehng  and  thought  that  belong  to  sanity  suffer  a  change, 
in  which  the  conduct  of  the  individual  indicates  a  departni-e  from  a  pre- 
viously existing  normal  standard.  His  new  beha^dor  places  him  at 
once  in  antagonism  to  the  conventions  of  the  intelligent  majority  of  Ms 
fellows.  Sometimes  he  never  reaches  a  point  of  ordinary  mental  integrity 
— ^he  is  the  product  of  neui'otic  stock,  the  degenerate  representative  of 
faulty  reproduction.  Under  some  circumstances  he  is  the  weak-minded 
one — is  the  inventor  "with  a  bee  in  his  bonnet'' — the  '-ne'er-do-well'" — 
the  "crank'" — the  reformer  who  suggests  gi'eat  issues  and  when  pos- 
sessed of  misplaced  power  persecutes  for  trifles,  always  mingling  with  his 
work  his  own  desu*e  for  notoriety.  Should  he  pass  thi'ough  childhood 
possessing  ordinaiy  power,  he  may  at  puberty  be  subjected  to  the  sti-ain 
of  development  and  go  under,  falHng  into  the  ranks  of  the  inciu-ably 
insane.  Others  of  poor  fiber  are  eonfi-onted  at  subsequent  life  epochs 
which  they  do  not  jjass  through  safely,  developing  evolutional  and  in- 
volutional insanities.  Some  indi^-icbTals  whose  weakness  takes  the  form 
of  moi'al  degeneration  may  manifest  such  slight  uitellectual  aberration, 
and  be  so  much  like  ordinary  depra-\'ed  j^eople,  as  to  bring  them  within 
the  pale  of  the  law,  which  is  at  times  indisposed  to  make  allowance  for 
then.'  doubtful  indications  of  insanity.  To  this  class  belong  the  matfoids 
described  by  Lombroso,  whose  unbalancing  is  a  mixtiu'e  of  cleverness 
and  duUness,  and  these  are  the  eccentrics,  in  whom  the  gap  between 
sanit}'  and  insanitj"  is  a  mere  crack. 

Insanity  is  then  usually  a  profound  alteration :  certainly  it  is  not.  as 
we  are  sometimes  induced  to  believe,  a  condition  that  may  originate  in 
a  day  or  two,  exist  for  a  few  hours,  and  disappear  as  quickly,  although 
occasionally  an  explosion  which  means  a  lapse  of  responsibihty  for  a 
short  time  may  occur  in  the  course  of  an  imperfectly  recognized  psychosis, 
which  laymen  are  apt  to  disregard. 

DEFIXITIOX. 

It  is  an  exceedingly  difficult  matter  to  give  a  perfectly  satisfactory 
definition  of  insanity,  or  one  that  will  meet  the  requirements  of  the  law. 
In  another  place  this  matter  will  he  gone  into  :  it  is  sufficient  here  for  me 
to  point  out  the  radical  difference  between  the  views  entertained  by  the 
doctor  and  lawyer  as  to  what  constitutes  mental  aberration,  though  a 
common  ground  is  being  gradually  attained.  The  latter  has  hitherto 
lieen  guided  by  the  hard  decisions  of  another  day,  when  a  lunatic  was 


INSANITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  53 

considered  as  "a  wild  animal/'  and  only  exensed  for  the  commission  of 
crime  when  he  knew  the  abstract  difference  between  riii'ht  and  wrong. 
His  standard  of  civil  responsibility  was  only  a  slight  grade  higher.  In 
a  recent  English  ease  {Rf</ina  vs.  JJimean)  an  American  expert*  who  ad- 
vanced the  ratioiuil  theory  of  will  enfeeblement  effected  a  revolution  in 
the  legal  pra(;tice  of  at  least  one  part  of  Great  Britain;  and  <jnly  a  few 
years  ago  the  writer  made  in  a  New  York  court  tlie  distinction  l^etween 
the  al)stra.ct  knowledge  of  right  and  wrong  and  the  (ipjdivd  knowlrdfjej 
which  meant  tlie  internal  power  of  discrimination.  {Peojile  vs.  LifhJaich- 
ricr.)  The  medical  idea  is  the  outgrowth  of  actual  familiarity  and  study 
■of  the  insane,  which  cannot  be  gained  in  any  other  way,  and  the  conclu- 
sions that  are  drawn  for  the  defense  of  the  weak  or  erring  are  as  fii-m  as 
those  of  the  clinician  who  estimates  the  significance  of  cough  or  rise  of 
temperature  in  diseases  the  pathological  nature  of  wdiieh  is  undisputed. 
There  is,  unfortunately,  a  group  of  lawyers  and  physicians  (I  am 
happy  to  say,  of  limited  size)  which  advocates  capital  punishment  for  all 
insane  nuirderers — a  proposition  which  can  only  be  tolerated  by  those 
whose  ideas  of  evolution  and  the  survival  of  the  fittest  dwarf  all  interest 
in  humanity.  Small  wonder  is  it  that  the  estimate  of  what  constitutes 
insanity  which  is  held  by  many  people  is  still  unsettled — many  technical 
writers  even  do  not  attempt  to  define  it. 

Bucknill  defines  insanity  as  "a  disease  of  the  brain  (idiopathic  or 
sympathetic),  affecting  the  integrity  of  the  mind,  whether  marked  by 
intellectual  ov  emotional  disorder." 

Maudsley's  definition  is  as  follows  :  "  Insanity  is,  in  fact,  disorder  of 
l.)rain,  producing  disorder  of  mind ;  or,  to  define  its  nature  in  greater 
detail,  it  is  a  disorder  of  the  supreme  nerve  centers  of  the  brain — the 
special  organs  of  mind — producing  derangement  of  thought,  feeling,  and 
action,  together  or  separately,  of  such  degree  or  kind  as  to  incapacitate 
the  individual  for  the  relations  of  life.  Mind  may  be  defined  pliysio- 
logicalty  as  a  general  term  denoting  the  sum  total  of  those  functions  of 
the  brain  which  are  known  as  thought,  feeling,  and  will.  By  disorder 
■of  the  mind  is  meant  disorder  of  these  f luu'tions."  It  will  l)e  seen  that 
Bucknill  insists  upon  actual  disease  of  the  bi-ain,  while  Maudsley  i-ather 
leans  to  the  view  that  the  mind  as  a  function  is  disordered,  he  makes 
the  distinction,  however,  calling  attention  to  the  fact  that  numerous  dis- 
■eases  of  the  brain  are  not  attented  by  insanifi/,  but  are  attended  by  mental 
■changes.  Spitzka  {TuseDnfi/:  Its  Classification,  J^iafpiosis,  and  Treaimeut, 
New  York,  1883)  formulates  a  definition  that  is  an  excellent  though  cum- 
bersome one,  but  its  length  is  justified  by  the  merit  of  its  comprehen- 
siveness :  "  Insanity  is  either  the  inability  of  the  individmil  to  correctly 
register  and  reproduce  impressicms  (and  (M)nceptions  based  on  these)  in 
sufficient  numl)er  and  intensity  to  serve  as  guides  to  actions  in  harmony 
with  the  individual's  age,  circumstances,  and  surroundings,  and  to  limit 
himself  to  the  registration  as  subjective  realities  of  impressions  trans- 
mitted by  the  peripheral  organs  of  sensation  ;  or  the  failure  to  properly 
coordinate  such  impressions  and  to  thereon  frame  logical  conclusions  and 
actions;  these  inabilities  and  failures  being  in  every  instance  considered 
as  excluding  the  ordinary  influences  of  sleep,  +'-ance,  somnanibulisin,  the 
•common  manifestations  of  the  general  neuroses,  such  as  epilepsy,  hys- 

*  Dr.  Walter  Kempster. 


5j.  A  8Ysti:m  of  legal  MELlCiyE. 

teria,  and  chorea  of  febrile  delirium,  coma,  acute  intoxications,  intense 
mental  j)i'eoccupation,  and  the  ordinary  immediate  effects  of  nervous 
shock  and  injiuy." 

I  have  for  some  years  advocated  the  use  of  a  definition  which,  though 
inferior  to  others  in  tidiness  of  description,  is  convenient  because  it  does 
not  so  directly  draw  the  medical  witness  into  a  wrangle  with  the  cross- 
examining  coimsel.  It  is  as  follows:  "Insanit}'-  is  a  condition  due  to 
disease  of  "the  brain,  and  expressed  by  impairment  of  feeling,  thought,  and 
volition."  Such  a  condition  must  not  be  confused  with  the  acute  toxaemia 
of  fevers,  di-ugs,  or  other  agents  of  the  kind.  I  make  this  qualification 
because  though  a  kind  of  temporary  aberration  may  result  from  alcohol,  for 
instance,  no  one  would  think  of  aj)pl5dng  the  term  insanity  to  a  state 
that  so  directly  implies  cause  and  effect.  Of  coiu'se  actual  insanity 
commonly  follows  the  protracted  use  of  alcohol  and  other  agents  of  the 
kind,  and  after  fevers  or  septic  diseases  we  find  prolonged  mental  disease 
dii-ectty  traceable  to  a  definite  and  adequate  cause. 

Dr.  Ray  adopted  the  use  of  the  qualifying  word  "  prolonged,"  because 
"there  are  many  conditions  in  which  there  are  temporary  departures 
from  the  normal  standard  of  thinking,  feeling,  and  acting,  which  are  not 
called  insanity,"  and  in  this  I  agree  with  him ;  but  it  is  difificidt  some- 
times to  fix  the  diu-ation  of  many  conditions  which  j)roduce  temporary 
mental  distm'bance,  or  to  say  when  insanity  really  begins. 

The  definition  of  insanity  is,  after  all,  the  pro^dnce  of  the  court,  and 
by  this  is  meant  the  legal  definition  which  determines  the  question  at 
issue.  It  is  the  simple  duty  of  the  medical  witness  to  j)resent  the  facts 
of  the  case  in  such  a  way  as  to  make  the  decision  of  the  com-t  possible, 
and  to  enable  the  latter  to  arrive  at  a  conclusion  which  will  be  possible 
under  law.  It  is  not  even  the  jmy's  dut}''  to  decide  the  question  of  law ; 
in  fact,  they  are  not  permitted  to  do  so ;  the_y  being  incompetent  so  far  as 
the  affixing  of  precedents  or  the  determination  of  definite  rules  is  con- 
cerned.    (Wharton  and  Stille,  vol.  i.,  p.  114.) 


CLASSIFICATION. 

The  changes  incident  to  unsettled  opinion  and  study  stand  in  the 
way  of  making  a  classification  which  is  entii'ely  satisfactory  or  always 
faitM'ul.  In  the  early  part  of  the  century  there  was  much  confusion, 
although  a  very  limited  number  of  terms  were  used  ;  and  this  disordered 
and  imperfect  understanding  of  the  subject  existed  until  about  fifty 
years  ago,  when  the  school  of  alienists  which  included  the  late  Forbes- 
Winslow,  Greisiuger,  Falret,  and  a  few  others,  seriously  attempted  to 
bring  order  out  of  chaos,  and  to  SN^stematize  the  nosology  of  mental  dis- 
ease. At  this  time,  and  even  until  comparatively  recently,  the  conven- 
tional di^^Lsions  of  insanity  were  only  four  or  five  in  number,  and  ft)r  the 
most  part  included  idiocy,  imbecility,  mania,  melancholia,  and  dementia. 
The  varying  and  relational  expressions  of  the  excited  or  depressed  states 
were  not  understood,  especially  when  they  appeared  alternately,  and  little 
or  no  attention  was  paid  to  the  mental  expressions  of  coarse  disease 
of  the  brain,  all  such  conditions  being  looked  upon  as  "  softening."  The 
other  school,  while  recogiiizing  the  existence  of  the  forms  of  insanity  jiist 
alluded  to,  still  paid  much  attention  and  gave  gi'eat  weight  to  so-called 


ly.'SjyiTl'  IX  ITS  MElJlLO-LEdAL   LEARIXGS.  55 

"  moral  insanity,"  wliich  many  of  them  believed  could  exist  without  any 
intelleetual  disturbance  whatever.  In  the  ranks  of  the  latter  Ix'longed 
Ray  and  afterward  Maudslcy,  but  it  was  not  until  al)out  a  quarter  of  a 
century  ago  that  a  greater  advance  was  made,  which  had  its  liirth  in 
Gernumy  and  has  resulted  in  a  very  comprehensive  and  ration;il  iiietliod 
of  classification  and  study,  its  strongest  exponents  being  Krafft-Elnng, 
Schiile,  Emminghaus  Kirchhoff,  and  otliers.  The  basis  of  the  German 
classification  rested  upon  the  consideration  of  the  degenerative  type. 

Much  of  the  confusion  that  resulted  from  the  descriptions  of  different 
authorities  has  depended  upon  the  coining  of  terms,  and  from  a  degree 
of  inexactness  which  has  arisen  from  attempts  to  classify  either  from 
the  somatic  or  epochal  standpoint. 

In  the  various  classifications  the  subject  is  approached  from  a  num- 
ber of  directions.  The  majority  are  based  upon  the  clinical  aspects  of 
the  disease,  and  the  symptom-manifestations  are  alone  regarded ;  others 
incline  to  the  adoption  of  terms  relating  to  the  epochs  of  life,  e.g.,  ado- 
lescent mid.  2)uhescent  insanities,  the  insanifi/  of  pregnancy,  of  lactation,  etc., 
climacteric  and  senile  insanities ;  other  alienists  give  prominence  to  the 
somatic  nature  of  the  insanity  or  the  etiological  factors,  Van  der  Kolk, 
Morel,  Skae,  Tuke,  Clouston,  and  various  English  wi'iters  strong!}^  ad- 
vocating and  generally  using  such  limited  terms — as  examples  may  be 
mentioned  viastiirhatic,  ovarian,  phthisical,  syphilitic,  rlienmatic,  puerperal 
insanities,  etc. 

While  the  use  of  these  terms  is  convenient  and  ahnost  general,  it  is 
sometimes  open  to  confusion  which  is  often  to  be  deplored  but  not 
always  avoidable.  As  has  been  said,  the  German  school  has  made  the 
gi'eatest  progress  in  the  systematic  and  advanced  study  of  psychopathol- 
ogy,  Krafft-Ebing  especially  having  recognized  the  importance  of  the 
underlying  condition  of  heredity.  He  and  his  followers  have  rather  con- 
sidered the  matter  with  reference  to  whether  there  was  a  congenital 
influence,  i.e.,  whether  the  insanity  appeared  in  connection  with  an  un- 
developed brain,  or  whether  the  insanity  was  an  acquired  one,  the  brain 
being  of  average  development ;  and  incidentally  whether  it  was  curable 
or  incurable.  This  seems  a  most  rational  and  scientific  theory.  He 
classifies  insanities  as  follows : 


A.  Mental  Diseases  op  tpie  Developed  Brain. 

I.    PSYCHONEUKOSES. 

1.  Primaiy  curable  couditious. 

a.  Melaueholia.  \  I^J^^^^^i 

6.  Mania.  \  Exaltation. 

\  Frenzy. 
c-  Stupor  or  curable  dementia. 
d.  Wabnsin. 

2.  Secondary  incurable  states. 

a.  Secondary  monomonia.     {Sccundarc  Vcrriicktheit.) 

,     m        -11  i-      S  Aijitata. 

h.    ierminal  dementia.  ■    .      ,i    .• 

{  Apatnetiea. 


56  ^   SYSTEM   OF  LEGAL  MEDLCLXE. 

n.  Psychical  Degexeratiye  States. 

o.  Constitutional  affective  insanity.     {Folie  Baisonante.) 
h.  Moral  insanity. 

c.  Primary  monomania.    {Frlmiire  Terriicktlieit.)    Persecutory,  gran- 

diose, erotic,  religious. 

d.  With  imperative  conceptions. 

e.  Insanities   which    are   developed  S  tP  +     •    '^ 

n  j.-t.  J.-       ^  \  Hvsterical. 

from  constitutional  neui-oses.     ^  nbochondi-iacal. 

/.  Periodical  insanities. 


m.  Cerebral  Diseases,  m'itk  Coxspicuous  Mental  St^iptohs. 

a.  Paretic  dementia. 
Z).  Lues  cerebralis. 

c.  Chi'onie  alcoholism. 

d.  Senile  dementia. 

e.  Acute  delirium. 

B.  Conditions  of  Mental  Weaknesses  tvith  Arrested  Development  of  the 

Cerebrum. 

a.  Idiocy. 
1),  Cretinism. 

This  classification,  vrhicli  is  practieallY  that  of  Spitzka  and  Kirchhoff, 
as  well  as  other  psychiatrists  who  have  recently  written,  has  at  least  the 
merit  of  considering  mental  disease  chieflj'  with  reference  to  its  expres- 
sion and  form,  while  the  qnestion  of  cause,  which  is  very  often  apt  to 
create  confusion,  is  left  unmentioned. 

The  wi'iter  has  for  some  time  been  impressed  with  the  possibility  and 
convenience  of  classifying  insanity  T^ith  reference  to  development,  believ- 
ing it  possible  to  avoid  the  faults  of  various  disputed  schemes.  With 
this  object  iu  view,  bearing  in  mind  the  question  of  normal  brain  de- 
velopment, he  has  divided  all  insanities  into  three  classes:  (1)  those  of 
evolution  ;  (2)  those  occuiTing  iu  connection  with  normal  development; 
(3)  those  of  involution. 

The  first  group  comprises  insanities  or  conditions  of  mental  weakness 
incident  to  the  period  when  the  brain  has  not  reached  its  full  develop- 
ment. Perhaps  it  has  suffered  arrest ;  perhaps  a  tax  incident  to  a  life- 
epoch  which  it  cannot  bear.  This  should  include  idiocy,  imbecility — 
which  comprises  the  forms  of  degenerative  disease  described  by  the  Ger- 
man school,  the  prunare  Yerriicliheit — the  adolescent,  circular,  epileptic, 
hysterical  insanities,  etc.  The  second  group  includes  those  forms  of 
mental  disease  which  are  quite  likely  to  appear  under  ordruary  cii'cum- 
stances,  disconnected  with  any  hereditary  etiological  factor,  the  develojD- 
ment  of  mind  being  unquestioned — the  simple  states  of  depression  and 
exaltation,  the  somatic  disorders,  whether  cansed  by  traumatism  or  gen- 
eral or  special  diseases;  and  the  third  those  forms  of  mental  disease 
where  there  is  dissolution  and  a  retrogression  to  amentia. 

These  thi'ee  forms  may  for  convenience  be  thus  grouped : 

I.  Evoll'tional  Insanities. 

(Hereditary.)     Idiocy;  cretinism. 

Insanities  ■with  limited  delusions. 

Insanities  with  predominant  moral  weakness. 


INSANITY  IN  US   MEDICD-LEGAL  JIKARIXGS.  57 

Perioilicnl  jiiul  alternating  insanities. 

Insanities  witli  inipei-ativo  concepts. 

Ei)iiei)tic,  liysterical,  and  jieriodical  alcoholic  insanities. 

Infantile  paretic  dementia  of  (Jlouston. 

Adolescent  insanity — acute  dementia  of  youth. 

II.  Insanities  op  Norma'l  Development. 

(Acquired.)     Mania.  }  Acute. 

Melancholia.  ^  Chronic. 
Traumatic,  toxic,  and  somatic  insanities. 

III,  Involutional  Insanities, 

(Ketrogressive.)     Terminal  dementia. 

Consecutive  dementia. 
Senile  dementia. 
Paretic  dementia. 

Maudsley's  classification  is  as  follows  : 

I.  Affective  or  Pathetic  Insanity, 

1.  Maniacal  perversion  of  the  affective  life.  \     (jpUrin  ' 

2.  Melancholia  depression  without  delusion.  <  m pianc'holia 

3.  Moral  alienation  proper  approaching  this,  but  not  reaching 

the  degree  of  positive  insanity  in  the  insane  temperament. 

II.  Ideational  Insanity. 

1.  General. 

a.  Mania. 

&.  Melancholia.  {  ^i?"*^- 
I  Chronic. 

2.  Partial. 

a.  Monomania. 

b.  Melancholia. 

d.  uementia.  ^  Secondary. 

4.  General  paralysis. 

5.  Imbecility. 

This  is  open  to  the  objection  that  so-called  moral  insanity  is  isolated 
and  that  so-called  partial  insanity  is  distinguished.  As  Wharton  says, 
*'  The  affective  life  is  made  independent  of  the  mind,  capable  of  being  dis- 
eased when  the  mind  is  undiseased." 


The  Causes  of  Insanity. 

Hereditary  influence  is  undoubtedly  the  greatest  factor  in  the  pro- 
duction of  insanity,  at  least  foi'ty  percentum  of  all  cases  being  traceable 
to  such  taint,  and  some  writers  make  a  stiU  greater  claim.  Clouston 
[Neuroses  of  IJevelopment,  p.  130),  who  is  a  close  observer  and  conservative 
authority,  says :  "  There  are  two  very  general  laws  or  tendencies  that 
prevail  in  different  families  as  to  the  neuroses.  In  one  case  nature  tends 
to  revert  back  to  the  normal  and  healthy  type,  and  disease  gets  less  in 


58  A   SYSTEM  OF  LEGAL  MEDICINE. 

intensity  in  different  generations,  till  it  disappears ;  in  others  it  gets 
accentuated  in  each  successive  generation — nervous  instaljility  or  neui-al- 
gia  or  headaches  in  parents  becoming  hysteria  and  chorea  and  asthma  in 
the  children,  epilepsy  in  the  grandchildren,  melancholia  in  the  great- 
grandchildren, and  adolescent  insanity,  with  its  dementia  or  idiocy,  and 
extinction,  in  the  next  generation."  So  far  as  the  rides  which  govern 
transmission  are  concerned  we  cannot  speak  with  much  positiveness. 
The  transmission  of  the  tendency  is  from  male  to  male  and  female  to 
female,  though  this  rule  has  its  exceptions.  Actual  insanity  may  not 
reappear  in  the  progeny,  but  as  some  other  peculiarity.  Of  course  if 
there  be  insanity  on  l)oth  sides  the  danger  is  greater  than  if  on  one  only ; 
and  the  existence  of  acquired  insanity  is  less  potent  in  its  evil  effects 
than  when  the  strahi  is  a  saturated  one.  In  courts  of  law,  when  dis- 
puted questions  arise,  it  will  make  a  gr^at  difference  if  the  origin  of  the 
insanity  of  the  parent  is  proved  to  have  been  at  a  period  after  the  birth 
of  the  child.  We  must  also  remember  that  the  inheritance  of  mental 
unsoundness  occurs,  as  Kirchhoff  points  out,  first,  in  the  majority  of  in- 
stances as  variable  symptom-complexes,  such  as  inebriety,  moral  perver- 
sion, criminal  impulses,  their  relations  and  transition  being  ii'regular; 
second,  a  grou]3  which  comprises  the  identical  form  of  insanity  which 
existed  in  the  progenitor,  hereditary  suicide  being  an  example. 

Men  of  genius  are  apt  to  have  insane  or  feeble-minded  children,  as 
are  consumptives  and  inebriates.  Historical  instances  of  this  are  numer- 
ous, and  we  either  find  criminality  or  the  evidence  of  weak-mindedness. 
8cipio  Africanus,  Petrarch,  Mozart,  Peter  the  Great,  Tacitus,  Mercadante, 
Thomas  Campbell,  Donizetti,  Volta,  and  Victor  Hugo,  all  had  sons  or 
daughters  who  were  insane.  The  influence  of  drunkenness  uj)on  impreg- 
nation is  generally  admitted,  and  the  writer  can  trace  in  more  than  one 
large  family  the  mental  weakness  of  certain  children  to  the  bad  habits 
of  the  father  during  their  procreation.  The  question  is  often  asked, 
How  soon  after  cure  can  persons  who  have  been  insane  run  the  risk 
of  ha^dng  children  who  are  not  liable  to  inherit  the  taiut?  I  think  the 
answer  can  be,  At  no  time*  after  the  existence  of  well-defined  insanity 
which  is  not  of  a  toxic  or  traumatic  nature  can  the  danger  of  hered- 
itary taint  be  said  to  be  absolutely  averted  by  treatment.  This  is  said 
with  the  fact  in  mind  that  occasions  do  happen  when  the  individual 
between  attacks  of  insanity  may  produce  children  Avho  are  appai"ently 
vigorous  both  physically  and  mentally.  Fleming  and  Demaux  adduce 
statistics  to  ineontestabl}^  prove  that  "  even  habitually  sober  parents  who 
at  the  moment  of  conception  are  in  a  temporary  state  of  di'unkenness 
beget  children  who  are  epileptic  or  paralytic,  idiotic  or  insane,  very  often 
microcephalic  or  with  remarkable  weakness  of  mind,  which  at  the  fii'st 
favorable  occasion  is  transformed  into  insanity.  Thus  a  single  em- 
brace, given  in  a  moment  of  drunkenness,  niaj^  be  fatal  to  an  entire 
generation."     (Lombroso.) 

Lucas  {Be  VUerklite)  refers  to  the  fact  that  all  the  descendants  of  a 
great  soldier — a  Hamburg  noble — ^became  insane  at  forty;  and  Lom- 
broso speaks  of  a  watchmaker  who,  having  recovered  from  an  attack 
of  insanity,  caused  l)y  the  Kevolution  of  1789,  finally  poisoned  himself; 
later  on  his  daughter  becaine  insane  and  fell  into  a  state  of  dementia ; 
one  of  his  Ijrothers  stuck  a  knife  into  his  own  abdomen ;  another  became 
a  drunkard  and  died  from  starvation  ;  his  sister,  who  was  of  poor  health, 


INSANITY  IN  ITS  MEDICO-LEGAL   BEARINGS.  59 

had  a  son  who  was  an  epileptic  Innatic,  a  dangliter  who  hecame  insane 
after  her  conlinenient  and  rejected  food,  an  infant  who  ivfnsed  to  be 
snckled,  and  two  others  wlio  died  of  ('erel)ral  diseases.  ]-5erti  has  col- 
lected the  records  of  one  family,  and  dnring  four  genci-ations  there  were 
eighty  individuals  descended  from  an  insane  melancholiac,  ten  subject 
to  insanity  (nearly  always  melancholia),  nineteen  who  were  uevu'otic, 
three  who  had  special  ability,  and  three  with  criminal  tendencies.  The 
disorder  was  aggravated  in  the  later  generations  and  developed  at  an 
earlier  age.  In  the  third  and  fourth  branches  the  insane  and  neurotic 
appeared  in  every  generation  ;  in  the  others  the  hereditary  influence 
passed  over  one  generation  in  the  men  and  two  in  the  women. 

So  far  as  the  heredity  of  the  criminal  instinct  is  concerned,  there  are 
numerous  recorded  examples  where  the  progeny  of  illustrious  men  have 
gone  to  the  bad  or  have  shown  a  weak  moral  nature  clearly  due  to  dis- 
ease. It  is  a  matter  of  easy  recognition  that  not  only  do  habitual  or  in- 
stinctive criminals  present  the  stigmata  of  degeneration,  but  often  be- 
come violently  insane. 

The  environment  of  the  individual  has  much  to  do  with  the  develop- 
ment of  mental  disease :  thus  we  find  that  those  in  America  who  live  in 
retired  country  places,  with  little  chance  for  diversion  or  intellectual 
stimulation,  more  readily  become  insane  than  the  inhabitants  of  great 
cities ;  and  this  condition  of  affairs  has  its  parallel  in  solitary  prison  con- 
finement, where  absolute  silence  is  imposed,  and  hallucinatory  insanity 
develops.  Rational  education  prevents  insanity  or  tends  to  regulate  the 
disordered  mind,  while  of  course  injudicious  and  tactless  care  increases 
the  weakness  which  tends  to  demorahzation.  This  applies  to  the  forcing 
of  weak  minds,  punishment,  and  a  neglect  of  the  physical  needs.  A])pli- 
catiou  and  system  operate  against  the  development  of  insanity,  and  a  sig- 
nificant proof  of  this  is  that  busy  merchants  and  students  often  undergo 
a  mental  break-down  when  they  relinquish  their  active  work  and  lose 
mental  stimidation.  According  to  Kirchhoff,  brain-workers  are  espe- 
cially endangered.  This  statement  will  have  to  be  taken  mth  modifi- 
cations, and  the  T^Titer  is  of  the  opinion  that  brain-work  only  of  a  dis- 
orderly or  excessive  character  is  that  which  is  injurious.  Under  such 
■circumstances  there  is  an  implied  iri'egularity,  an  excessive  use  of  the 
amotions,  and  an  output  of  force  that  brings  exhaustion. 

Predisposing  diseases  and  bad  habits  of  course  have  much  to  do  "svitli 
the  genesis  of  all  forms  of  mental  disease,  and  these  may  be  enumerated 
as  syphilis,  the  opium,  cocaine,  and  the  chloral  habits,  alcoholism,  and 
dissipation  generally. 

The  other  causes  of  insanity  may  be  di\dded  into  the  Mred  physical 
and  the  indirect  plujsical  and  emotional  causes.  (Burr,  PsyclwJogu  and 
Mental  Disease,  Detroit,  1894.*) 

The  former  include  injury  and  its  results,  bodily  disease — such  as 
oancer,  pulmonary  affections,  Bright's  disease,  eardine  disease,  rheuma- 
tism, uterine  and  ovarian  disease,  hemorrhoidal  or  other  losses  of  blood 
— metallic  and  bisulphide-of -carbon  poisoning,  and  sexual  excitement,  the 

*  Bnrr  estimates  the  frequency  of  cause  as  follows  : 
Direct  physical,  about  36  percent. 
Indirect  physical  and  emotional,  about  14  percent. 
Vicious  haluts,  about  2;")  percent. 
Constitutional  and  evolutional  causes,  about  25  percent. 


60  ^  systi:m  of  legal  medicine. 

effects  of  child-bearing  (piierperal  insanity)  and  prolonged  nursing  (lacta- 
tional insanity).  The  resulting  pathological  condition  is  one  of  exhaus- 
tion through  shock,  inflammation  or  depletion  through  drainage,  poison- 
ing of  the  nervous  substance,  or  various  alterations  in  the  integrity  of 
centripetal  sensory  conduction. 

The  somatic  forms  of  insanity  are  not  often  recognized  by  persons 
who  are  not  careful,  the  mental  disturbance  overshadowing  the  other 
organic  disturbance.  Phthisis  sometimes  produces  in  its  last  stages  a 
derangement  attended  by  alternating  dej)ression  and  exaltation,  in  which 
delusions  of  a  grandiose  character  are  expressed.  Asthma  is  sometimes 
likely  to  give  rise  to  melancholia,  but  whether  this  is  the  result  of  the 
defective  aeration  of  the  blood  or  the  action  of  the  remote  hereditary 
predisposing  cause  that  is  usually  behind  the  asthma  itself  it  is  difficult 
to  say.  La  grippe,  which  in  large  measure  may  be  said  to  be  a  disease 
of  the  respiratory  organs,  has  played  a  part  of  no  small  importance  in 
the  genesis  hot  only  of  an  acute  confusional  insanity,  but  of  occasioning^ 
a  permanent  delusional  insanity. 

Cardiac  lesions  are  at  best  only  associated  conditions,  and  are  not 
important  etiological  factors.  In  cerebral  hyperasmia  of  the  passive 
variety  we  are  apt  to  have  depression,  and  the  hypertrophy  of  the  right 
ventricle  with  which  it  is  often  associated  may  possibly  be  regarded 
as  a  causative  element.  "  It  is  a  fact  that  patients  suffering  from  car- 
diac lesions  are  more  likely  to  develop  anxious  and  suspicious  delusions 
than' those  of  an  opposite  nature."  (Spitzka.)  Circulatory  disorders,  such 
as  exophthalmic  goiter,  which  is  most  common  in  women,  are  attended 
by  attacks  of  depression  often  approaching  simple  melancholia  in  degree. 
The  fact  should  not  be  lost  sight  of  that  in  secondary  dementias  due  to 
cerebral  thrombosis  or  embohsm,  the  heart  will  probably  show  some  evi- 
dence of  disease. 

Rheumatism  is  an  uncommon  cause.  Its  pathological  result  is  usually 
an  irritation  or  actual  inflammation  of  the  cerebral  meninges,  with  press- 
ure symptoms,  a  rise  in  temperature,  headache,  a  confusional  condition 
often  approaching  delirium,  which  is  less  violent  during  the  day.  The 
prognosis  is  good,  though  dementia  sometimes  supervenes, 

BrigJiVs  disease  is  an  occasional  cause  of  insanity. 

Uterine  and  ovarian  diseases  are,  I  am  convinced,  not  nearly  so  impor- 
tant causes  of  insanity  as  is  generally  supposed.  Especially  is  this 
the  case  when  the  uterus  is  displaced.  It  is  true  that  in  feeble-minded 
women  the  uterus  is  often  found  undeveloped,  as  are  other  organs ;  and 
although  many  operations  of  the  most  diverse  character  have  been  per- 
formed upon  insane  women,  I  do  not  believe  the  results  are  ever  as  satis- 
factory as  might  be  inferred  from  the  enthusiasm  and  reports  of  the 
operators.  Personal  experience  which  has  been  recorded  elsewhere  per- 
mits me  to  speak  authoritatively  in  regard  to  at  least  one  gynecological 
procedure,  that  of  oophorectomy.  Pelvic  disease  attended  by  profuse 
hemorrhage  is  often,  however,  a  cause  of  insanity,  notably  of  the  de- 
pressed form,  and  I  have  witnessed  repeated  cures  when  the  loss  was 
arrested  and  the  drain  stopped. 

Local  excitement  which  is  due  to  a  variety  of  causes,  such  as  mastur- 
bation or  the  irritation  of  vaginal  discharges,  is  apt  to  result  in  a  moral 
disturbance,  introspective  insanity,  and  hysteroid  disorders  under  fitting 
circumstances.     So  far  as  the  psychoses  which  depend  upon  pregnancy 


[XSJXITV  IN  ITS  MEDICO-LEGAL   BEARINGS.  Gl 

and  delivery  are  concerned,  there  is  much  to  be  learned  about  their 
patIiog(uiy.  The  general  disturbance  of  the  sympathetic  system  during 
the  nine  months  before  delivery  is  in  some  women  a  serious  one,  and 
the  tax  u))()n  the  vital  powers  is  very  great,  so  that  in  women  witli  a 
predisposition  to  mentul  trouble  there  often  occurs  a  form  of  aberration 
of  variable  degree  and  continuance.  This  is  due  sonietimes  to  uneniia 
or  other  forms  of  bl()()d-})()isoniug,  to  variations  in  the  l)lood-pressure, 
and  to  moral  causes.  Illcgitiinate  pregnancy  is,  for  the  last  reason,  par- 
ticularly jipt  to  be  attended  by  insanity.  The  insanities  of  a  puerperal 
nature,  like  those  incident  to  prolonged  lactation,  are  due  either  to  se2:)tic 
poisoning,  depletion  after  hemorrhage,  or  exhaustion.  Climacteric  in- 
sanity is  due  to  the  profound  process  which  indicates  the  commencement 
of  involution.  This  epoch  plays  the  part,  sometimes,  of  changing  existing 
neuroses,  transforming  migraine  into  epilepsy  or  epilepsy  into  insanity. 

JExces.sire  sexual  excitement  is  likely  to  enfeeble  the  central  nervous 
system  to  an  extent  which  leads  to  the  production  of  mental  impairment, 
though  as  a  rule  nature  regulates  capacity,  and  sexual  ajipetite  is  sated 
by  exhaustion  of  the  spinal  centers  and  fatigue  of  the  normal  ideational 
centers.  Of  course  with  unnatural  abuses  which  are  suggested  by  a  cen- 
tral condition  of  existing  mental  disorder,  the  individual  may  goad  his 
wearied  sexual  apparatus.  Those  who  resort  to  false  means  of  gratifica- 
tion not  uurarely  belong  to  the  class  of  moral  perverts,  and  their  ^dcious 
appetite  is  the  product  of  a  diseased  imagination.  In  established  insan- 
ity, especially  dementia,  the  act  of  mastui'bation  is  the  direct  result  of 
the  insanity. 

Einotional  causes,  such  as  grief,  shock,  or  fright,  are  alleged  to  have 
much  to  do  with  the  genesis  of  mental  disease.  These  influences,  I 
think,  are  often  exaggerated,  the  effect  necessary  to  unbalance  the  mind 
depending  upon  the  existence  of  hereditary  influence,  or  a  previously 
exhausted  nervous  system  which  is  due  to  brooding,  insomnia,  and 
irregularities.  Kirchhoff  looks  uj^on  psychical  influences  as  important, 
especially  those  which  are  concealed.  "  Constant  gnawing  fears,  without 
actual  material  losses,  may  lead  to  the  mental  break-down.  We  always 
find  two  factors  in  these  causes,  viz.,  the  repeated  and  constant  occur- 
rence, and  the  painful  element  of  feeling.  Both  together  prevent  the 
inhibitory  counter-effects  of  other  ideas."  Overwork,  anxiety  without 
the  prospect  of  affairs  getting  better,  thwarted  ambition,  and  failure,  all 
under  certain  circumstances  act  as  causes.  Disappointment  in  love  and 
marital  discord  have,  I  believe,  little  to  do  with  insanity,  nor  has  re- 
ligious concentration,  unless  there  is  a  degenerative  basis. 

The  feigning  of  insanity  undoubtedh^  results,  in  some  cases,  in  the 
establishment  of  a  real  psychosis.  I  know  of  two  such  cases,  and  there 
can  be  no  doubt  of  its  easy  production  in  neurotic  individuals  who  are 
long  incarcerated,  a  laborious  effort  at  deception  being  made  which 
implies  morbid  concentration. 

The  usually  curable  insaidties  due  to  febrile  disease  are  undoubtedly 
explained  by  microbic  infection  or  exhaustion.  The  mental  disorder 
ordimirily  follows  the  febrile  condition,  and  is  characterized  by  a  con- 
fused train  of  hallucinations,  illusions,  and  delusions,  with  moments  of 
apparent  lucidity.     Suicide  is  not  unconmion. 

hiJHvles  to  the  brain  are  apt  to  develop  or  cause  insanities  of  a  more  or 
less  constant  and  progressive  nature,  though  sometimes  a  blow  upon  the 


62  A   SYSTEM  OF  LEGAL  MEDICIXE. 

head  will  modify  or  cure  an  existing  insanity.  Affections  of  the  memoiy 
from  shock  are"  common  and  of  sudden  or  rapid  origin,  or  an  inflam- 
matory condition  may  be  inaugm-ated  which  is  expressed  by  the  hve- 
liest  spnptoms,  such  as  illusions,  delusions,  and  violence,  which  lead  to 
outrag-eous  assaults.  A  blow  may  effect,  sometimes,  a  complete  transfor- 
mation in  the  iudiwdual,  turning  a  peaceable,  high-minded,  honorable 
man  into  a  lying,  brutal  thief. 

Intracraiuaf disease,  the  most  important  etiologicaUy  being  menm- 
gitis,  not  only  effects  a  blight  in  development,  Imt  gives  rise  to  ^-arious 
psychoses,  such  as  rmbecility,  epilepsy,  hysterical  insanity,  delusional 
conditions,  and  loss  of  memory,  with  ultimate  dementia.  The  cutting 
off  of  the  blood-supply,  for  example,  through  an  occlusion  of  one  of  the 
middle  cerebral  arteries,  is  apt  to  lead  to  softening  of  a  considerable 
cortical  area,  with  dementia  as  a  consequence. 


The  Course  and  Termination  of  Insanity. 

The  eom-se  of  insanity  is  nearly  always  downward  and  the  proportion 
of  real  cui-es  comparatively  small.  Statistics  are  apt  to  give  false  im- 
pressions, as  they  usually  do,  and  the  temptation  to  make  good  records 
has  occasionally  led  the  chi-onicler  to  amplify  the  list  of  recoveries. 
Earle  [CurahUity  of  the  Insane)  cites  the  instance  of  one  woman  who 
was  reported  as  cured  twenty-two  times  in  twelve  successive  months, 
although  the  fact  probably  was  that  she  had  twenty-two  paroxysms  of 
mania  dming  this  time.  This  careful  oliserver  collated  the  statistics  of 
twenty  American  asylums  and  fomid  the  percentage  of  recovenes  for 
five  years  to  be  29.9,  which  is  a  much  smaller  nimiber  than  it  was  dming 
either  of  two  periods  of  five  years  that  preceded ;  shoT\ing  that  there  was 
a  better  system  of  reporting,  or  that  the  means  of  cm-e  and  treatment  are 
more  imperfect  than  in  the  past,  which  is  improbable,  or,  what  is  more 
likely,  that  a  mistake  had  been  made.  He  appends  another  table,  which 
includes  the  statistics  for  one  year  relative  to  the  insane  in  58  American 
asjdums:  of  14,372,  27.88  percent,  recovered,  and  20.74  percent,  died. 
The  prognosis  of  insanity  as  a  rule,  therefore,  is  not  good,  and  the  outlook 
becomes  more  unfavorable  as  the  time  of  improvement  is  prolonged. 

Blandford  {Insanity  and  its  Treatment,  3d  ed.,  1886,  p.  249)  presents  a 
table  showing  the  history  of  244  insane  persons  who  died  at  or  after 
discharge  fro'm  the  York  Retreat  from  1796  to  1840,  with  the  nimiber 
who  died  during  or  after  recovery  from  the  fii'st  or  subsequent  attacks 
of  mental  disease : 

Recovered  from  the  First  Attack. 

Died  Imaiie  Recovery  Per-  Had  Subsequent  Attack. 

Cases  folloived  through  Life.        during  the  Total.         manent. 

First  Attack.  Died  Sane.    Died  Sane.  Died  Jnsaiu.     Total. 

Males  113  55  58  21  6  31  37 

Females 131  58  73  24  14  35  49 

Total 244  113  131  45  20  66  86 

These  cases  were  well  watched  and  recorded,  and  the  deductions  to  be 
draA^m  are  like  those  of  Earle — neither  favorable  nor  encoiu-aging. 

The  insane  die  most  often  from  exhaustion.     Sometimes  the  acute 


INSANITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  G3 

stage  is  fatal  in  a  week  or  two  after  complete  insomnia  and  i-efnsal  of 
food,  although  in  most  cases  hypnotics  and  artificial  feeding-  will  keep 
many  of  these  cases  alive.  Heart  failure  is,  however,  sometimes  induced, 
especially  in  eases  whose  real  condition  has  not  been  appreciated,  and 
who  have  been  kept  at  home  and  ])ermitted  to  exhaust  tliemselves. 
.Sometimes  malpractice  upon  the  part  of  an  ignorant  ph^'sician  or  uurse 
will  result  in  the  death  of  a  patient  from  careless  feeding.  I  was  called 
to  see  a  case  where  the  liquid  nourishment  liad  been  forced  tlirough  a 
soft  catheter  into  the  trachea,  the  patient  being  unconscious  at  the  time. 
A  resulting  mechanically  produced  pneumonia  proved  fatal  in  a  few  days. 
Death  from  exhaustion  in  acute  cases  may  be  prolonged  after  a  gradual 
and  unpreventable  waste  of  energy,  and  such  an  ending  sometimes  oc- 
<iurs  in  acute  mania,  the  brain  after  death  presenting  great  Ini^era^mia  or 
sometimes  no  gross  change  whatever.  Rapid  exhaustion,  with  the  de- 
velopment of  unsystematized  delusions  and  hallucinations,  is  a  grave 
indication. 

Chronic  cases  show  great  vitality,  occasionally  pli^vsical  improvement, 
and  a  great  accumulation  of  fat  occurring  after  a  time  ^^'ithout  any 
mental  improvement.  In  fact  this  condition  of  affaii'S  is  always  un- 
favorable. 

Acts  of  extravagance,  so-called  impulses  of  an  immoral  character,  and 
sexual  abuses  in  a  patient  with  an  insane  family  history  are  bad  signs. 

Insanities  expressed  by  periodical  attacks  have  a  liad  prognosis.  Even 
though  the  interval  of  lucidity  may  be  marked  it  is  unsafe  after  two 
attacks  of  mental  aberration  to  make  favorable  p]*edictions.  Other 
exacerbations  are  probable,  and  a  termination  at  some  later  time  in 
dementia  is  to  be  looked  for,  the  intervals  usually  growing  shorter  in  such 
«ases.  If  the  recovery  from  an  attack  of  mental  derangement  be  veiy 
rapid  the  indications  are  that  there  will  be  a  reciu-rence.  Curable  cases 
of  any  kind  as  a  rule  present  a  gradual  disappearance  of  symptoms ;  the 
patient  showing  his  favorable  progress  by  anticipating  the  futm-e, 
making  ])lans,  and  analyzing  his  old  delusions  after  explaining  them 
satisfactorily.  The  general  physical  condition  of  the  patient  improves ; 
his  skin  becomes  moist;  sleep  returns;  and  should  the  patient, be  a 
woman,  sometimes  the  menstrual  flow  is  reestablished.  One  writer  caUs 
attention  to  the  return  of  former  ailments  as  a  coincident  indication  of 
commencing  recovery.  However,  a  cunning  lunatic,  seeing  in  what  num- 
ner  his  false  ideas  impress  others  whose  favor  he  seeks  to  obtain,  will 
conceal  and  disguise  his  real  delusions  as  far  as  he  can.  This  often  oc- 
curs in  connection  with  the  desire  for  lilierty.  Sometimes  he  cannot  thus 
dissemble,  disclosing  another  delusion  at  the  same  time  that  he  strives  to 
control  the  one  that  has  gotten  him  into  troul)le.  He  may  deny  his  delu- 
sions to  one  person,  l)ut  express  them  to  others,  or  he  may  verbally  dis- 
claim any  mental  infirinity  or  false  belief  while  he  still  shows  it  in  his 
manner  and  dress,  or  in  his  unconscious  actions.  A  fixed  delusion  may 
lead  to  exhaustion  and  starvation  through  refusal  of  food.  The  case  of 
a  patient  occurs  to  the  writer  whose  delusions  were  of  a  religious  char- 
acter. He  would  not  ride  on  Sunday  even  to  church,  and  displayed  a 
morbid  conscientiousness  of  an  extreme  kind.  As  his  s^-mi>toms  grew 
worse  and  insomnia  could  not  lie  overcome  by  ordinary  means  he  was 
sent  to  an  asylum,  where  his  condition  did  not  mend.  He  still  mani- 
fested a  fear  that  he  might  do  something  to  shock  the  ^Umighty.  and 


64  ^   SYSTEM  OF  LEGAL  MEDICINE. 

absolutely  refused  to  sit  down.  He  stood  so  constantly  that  his  feet 
and  ankles  became  oedematous  and  he  grew  more  and  more  weak,  as 
coupled  vrith  this  was  a  refusal  to  take  food.  It  was  fina%  found  nec- 
essary to  strap  him  in  bed,  but  despite  artificial  feeding  and  enforced 
rest  he  faded  and  died  in  collapse. 

Auditory  hallucinations  are  indications  of  a  more  grave  form  of  in- 
sanity than  visual,  and  the  same  is  true  of  sensory  and  olf active.  In 
verbigeration  or  confused  speech,  the  compounding  of  words  attests  an 
involved  dissolution.  Many  forms  of  chi'onic  insanity  are  characterized 
by  periods  of  remission.  Recm-rent  insanity,  or  folk  circidaire,  is  one  of 
such.  In  the  intervals  the  patients  are  apparently  so  much  themselves 
that  they  are  treated  as  sane  persons.  Paretic  dementia,  or  general  par- 
alysis, is  another  affection  in  which  such  an  apparent  return  to  sanity  is 
found. 

Changes  in  the  organic  structures  of  course  point  to  an  unfavorable 
course  and  ending.  This  is  true  of  the  destruction  of  the  cortex  which 
belongs  to  paretic  dementia,  a  disease  of  remarkably  rapid  progress. 
"With  extreme  exhaustion  due  to  a  continued  Hght  gTade  of  excitement 
we  are  apt  to  have  an  oedema  of  the  brain,  with  collapse.  Tliis  is  par- 
ticularly time  of  auEemic  cases.  The  prognosis  of  insanities  due  to 
epilepsy,  meningitis,  sunstroke,  injury,  and  syphihs  is  bad;  and  when 
lesions  exist  and  produce  progi-essive  paralysis,  convulsions,  obstinate 
disorders  of  motihty  or  ocular  disease,  we  can  never  take  a  favorable 
view  of  the  patient's  condition. 

The  progressive  appearance  of  symptoms  in  childhood  or  advanced 
age  is  bad.  In  the  latter  case  an  early  fatal  termination  is  to  be  feared,, 
as  the  powers  of  resistance  are  feeble.  The  insanities  of  childhood  are 
usually  due  to  hereditary  influences ;  and  though  the  psychoses  of  pid^erty 
when  acquii'ed  are  favorable,  the  reverse  is  true  where  the  insane  dia- 
thesis exists.  It  is  held  that  "  there  is  a  difference,  as  regards  prognosis^ 
between  hereditary  psychoses  wliose  outbreak  is  due  to  late  accidental 
causes,  and  those  in  which  heredity  has  produced  a  morbid  development 
of  character  in  early  childhood.  If  the  patient  with  hereditary  taint  has 
been  mentally  normal  until  his  attack  of  insanity,  the  prognosis  of  the 
single  attack  is  more  favorable  than  in  non-hereditary  cases,  but  there  is 
a  gi-eater  predisposition  to  relapses."     (Kii-chhoff.) 

The  following  table  is  presented,  which  is  based  upon  the  oliservations 
of  Krafft-Ebing,  Schiile,  Spitzka,  Ku-chhoff,  Clouston,  Blandford,  Savage^ 
Stearns,  and  my  own  experience,  which  indicates  the  gravity  of  symp- 
toms alone  or  associated : 

Uufavordble  Indications.  Favorable  or  not  absolutely  Bad  Indications^. 

States  characterized  by  slowly  developing  Rapidly  developing  tmconseiousness,  ex- 
loss   of   consciousness,  indifference,   or  cept  in  repeated  attacks  like  epilepsy, 
hebetude,  with  staring. 

Loss  of  facial  expression ;  organic  flatten-  Retui'n  of  harmonious  play  of  facial  mus- 
ing or  change  in  shape  of  featui'es.  cles  ;  quick  reflexes  of  emotional  states. 

Moral  indifference;    degeneration  shown  Self-defilement  in  puerperal  condition  or 

by   impulsive    criminal    or   destructive  acute  mania  not  necessarily  bad  ;  incon- 

acts,    including    filthy  practices,    self-  tinence  ta  acute  conditions  compatible 

defilement ;  protracted  indifference,  with  with  recovery, 
involuntary  discharges   of   contents  of 
bladder  anil  rectum. 

Protracted  sexual  excitement;  manifest- 


IXSJXITF  IX  ITS   MKDlCO-LEdAL   JIEAUIXC.S. 


G.3 


Unfavorable  Indications. 

ation  of  sexual  excitement  or  perver- 
sion in  extreme  youth  or  old  age. 
Tjoss  of  sleep,  with  exhaustion. 

Motiveless  acts  subsequently  justified  by 

patient. 
Imperative  concepts  of  long  duration  and 

their  results. 
Periodical  attacks. 

^Uontinued  depression  and  absorption, 
with  picking  of  fingers  and  mucous 
membrane. 

Limited  delusions  constantly  expressed. 

Tendency  to  homicide  or  suicide,  with 
continued  depression. 

Auditory  hallucinations. 


Unequal  contraction  or  minute  symmet- 
rical contraction  of  pupils. 

Verbigeration. 

Chronic  alcoholism  or  coarse  cerebral  dis- 
ease. 

Oongeuital  or  other  stigmata. 

dutaneous  anaesthesia ;  tremor,  with 
paralysis ;  ocular  symptoms ;  optic 
neuritis ;  absent  or  greatly  increased 
tendinous  reflexes. 

Catalepsy,  with  verbigeration. 

•Constant  drooling  of  saliva,  with  charac- 
teristic posture. 

Involuntary  discharges  as  result  of  indif- 
erence,  as  in  dementia. 


Favorable  or  not  ahsoluielij  Had  Indications. 


Increase    of  weight,  with  coiTe.sponding 

mental  broadening. 
Unconscious    acts   of   violence    in   acute 

mania  as  result  of  transient  delusion. 


Rapidly  developing   mania,  with  sudden 

changes  to  depression. 
Simple    depression,  without    fixation    of 

ideas ;  excitement ;  irregularity. 

Confusional  insanity. 


Visual  hallucinations. 

An  existing  bodily  condition  such  as  anae- 
mia or  a  febrile  disease  to  account  for 
the  mental  change. 

Dilatation  of  pupils. 


Temporary  causes,  such  as  the  influences 
of  pregnancy  and  the  puerperal  state. 

Paroxysmal  hysterical  attacks ;  hyperfes- 
thesia,  with  increased  reflexes. 


Catalepsy,     with     simple     or     apathetic 

melancholia. 
Spitting  as  result  of  delusion. 

Involuntary    discharges   due   to   indiffer- 
ence, as  in  mania. 


Excitable  forms  of  disease  are  more  hopeful  than  those  in  which  de- 
pression predominates,  and  Avhile  an  attack  of  acute  mania  may  recover 
in  two  or  tliree  months,  one  of  decided  melancholia  is  at  best  apt  to  drag 
on  for  a  much  longer  time,  or  actually  end  in  dementia. 

Alcoholic  and  toxic  insanities  are  recoverable  unless  the  organic 
changes  are  profound  or  there  is  a  transmitted  inherent  weakness. 


The  Morbid  Anatomy  of  Insanity. 

In  all  cases  the  configuration  of  the  brain,  its  size,  and  the  depth  of 
the  gray  cortical  substance,  as  well  as  the  signs  of  recent  disease,  must 
be  considered.  If  a  small  brain  has  an  increased  specific  gravity  which 
is  disproportionate  with  its  size,  we  shall  probably  detect  the  existence  of 
sclerosis  and  atrophy.  It  has  been  found  that  the  weight  of  this  organ 
undergoes  decided  modifications  in  connection  with  insanity,  and  Clap- 
ham  {^Yest  Riding  Reports,  vol.  \\.,  p.  11)  presents  a  table  which  includes 
twelve  nnndred  cases  of  insanity.  It  would  appear,  according  to  this, 
that  the  brain-weight  is  greater  in  the  insane,  between  the  ages  of  forty 
.and  fifty  in  women  and  between  fifty  and  sixty  in  men,  than  at  any  other 


66  A   SYSTEM  OF  LEGAL  MEDICIXE.. 

time ;  that  in  the  male  the  brain  weighs  more  proportionate!}^  in  idiocT 
than  it  does  in  the  female ;  that  its  average  weight  is  greater  in  mania 
than  melancholia,  and  in  other  forms  of  acnte  insanity  than  in  senile  or 
organic  dementia,  imbecility,  or  paretic  dementia. 

Grammes. 

n-  m„-,^»,j.„7^,.      Cerebellum,  Pons,        .„„ 

Disease.  Encephalon.         and  Medulla.  ^^^■ 

Idiocy 1148.947  156.7  21.94 

Imbecility 1285.009  174.6  36.2 

Dementia  (simple) 1310.956  169.7  49.132 

Seuile 1278.382  163.8  64.843 

Organic 1291.949  170.5  53.810 

Mania,  melancholia,  and  acute  forms .  1350.425  172.8  42.082 

General  paralysis 1270.271  174.0  41.610 

Epileptic  insanity 1314.410  164.4  36.646 

Chronic  mania 1327.267  171.9  46.863 

Brain  wasting 1256.644  164.3  60.929 

We  are  enabled  to  detect  the  depth  of  the  gray  matter  of  the  con- 
volutions by  means  of  an  instrument  invented  by  Dr.  Herbert  Major. 
This  consists  of  a  glass  tube,  finely  gi-aduated,  by  which  portions  of  the 
cortex  of  the  brain  may  be  removed  by  thrusting  the  gauge  into  the 
particular  convolution  the  depth  of  which  it  is  desired  to  determine,  and 
remo^dng  a  plug  of  white  and  gray  matter.  It  will  be  found  that  the 
depth  of  the  gray  matter  in  certain  forms  of  insanity  has  undei-gone 
material  diminution ;  and  in  those  where  congenital  deficiency  is  sus- 
pected we  shall  find  that  the  proportion  of  the  white  and  gray  substances 
is  very  much  changed,  the  latter  being  reduced.  In  measming  the  depth 
of  the  gray  substance  of  the  convolutions  it  will  be  found  that  it  is- 
reduced  from  eight  one-liundi^edths  of  an  inch  to  six  or  seven  one-hnn- 
di'edths.  Bucknill  and  Tuke  prefer  measurements  made  with  a  hair- 
divider,  a  variet}^  of  small  compass,  to  the  instriiment  invented  by  Herbert 
Major. 

Benedikt  and  other  German  waiters  place  great  reliance  upon  pecul- 
iarities in  the  arrangements  of  the  convolutions  and  sulci  in  the  brains 
of  insane  criminals.  While  I  do  not  beheve  that  Benedikt's  ideas  are 
always  susceptil)le  of  proof  so  far  as  it  is  possible  to  definitely  connect 
gyral  and  fissural  anomalies  with  specific  forms  of  moral  depaiture,  it 
is  still  a  noteworthy  fact  that  in  the  cerebrum  of  the  congenital  criminal 
there  is  great  complexity  and  irregularity  in  the  arrangemeut  of  the  con- 
volutional  folds  and  fissures.  In  his  book  upon  the  subject  he  presents- 
a  number  of  autopsies  the  subjects  of  which  were  criminals,  and  in  every 
instance  there  were  certain  peculiarities  which  he  has  minutely  detailed,, 
and  these  consisted  not  only  in  the  excessive  fissure  development,  but  in 
the  repeated  existence  of  asymmetries  of  the  brain  and  the  skull  itself. 
The  parietal  lobe  was  usually  dwarfed,  the  cerebellum  was  only  partially 
covered  by  the  occipital  lobe,  and  there  was  a  deficiency  in  Wernicke's 
fissure ;  the  interparietal  fissure  communicated  very  frequently  with  the 
fissures  of  Sylvius,  and  the  parieto-occipital  with  the  horizontal  and  inter- 
parietal. Asymmetry  of  the  two  hemispheres  and  convolutional  errors 
of  development  should  always  be  noted. 

The  brain  in  imbeciles  and  idiots  presents  malformations  and  arrest- 
ment of  development  Avhicli  ai'e  quite  characteristic.    These  modifications 


JXSAXITl'  IX  ITS  MEDICO-LEGAL  BEARINGS. 


67 


take  the  form  of  atropliios  of  parts  or  gi-oups  of  convolutions  of  the 
cortex ;  and  the  partial  atrophies  are  revealed  by  a  thinning  of  the  folds, 
and  hy  a  eorrespondiug-  enliirgement  and  deptli  of  certain  fissures.  These 
are  prinei2)ally  in  the  frontal  convolutions,  which  present  irreg-ularities  of 
formation.  Asynnnetry  is  very  noticeable  in  the  brains  of  idiots,  the  two 
lobes  often  showing  a  want  of 
correspondence  which  is  decided, 
as  well  as  a  poverty  in  the  num- 
ber and  depth  of  the  sulci ;  and 
(ionvolutional  flattening.  Such 
brains  are  often  exceedingly 
small  and  unformed.  That  pre- 
sented by  Ireland  is  a  good  ex- 
ample (Fig.  13)  of  imperfect  de- 
velopment. From  a  pathological 
point  of  view  we  find  arrested 
development  depending  upon  de- 
fects in  the  apparatus  of  nour- 
ishment in  the  cortical  sub- 
stance. 

Luys  {Traife  CJinique  et  Fra- 
tique  des  Maladies  2[entales,  1881) 
has  devoted  much  attention  to 
the  subject  of  the  convolutional 
anatomy  of  the  brain  in  the  in- 
sane. He  finds  that  the  fissure 
of  Sylvius  is  usually  enlarged, 
and  extends  much  farther  back 
than  it  does  in  the  normal  brain, 

exposing  the  insula ;  while  the  fissure  of  Eolando  is  nearly  normal,  but 
its  continuity  is  interrupted  by  ii-regularities  which  jut  out  from  the 
marginal  convolutions. 

This  writer  has  collected  pathological  data  of  great  interest,  showing 
that  certain  definite  convolutional  changes  are  to  be  found  in  many  cases 
of  insanity.  According  to  him,  the  most  frequent  are  those  seen  in  the 
frontal  convolutions,  which  are  much  more  irregularly  disposed  in  the 
right  than  in  the  left  hemisphere.  The  first  frontal,  especially,  is  xqyy 
frequently  atrophied  and  diminished  in  breadth.  Luys  has  found  in  a 
case  with  well-marked  hallucinations  that  in  the  internal  aspect  of  one 
cerebral  hemisphere  the  paracentral  lol)ule  was  prominent,  the  first  frontal 
depressed,  and  the  second  frontal  had  undergone  at  its  anterior  part  de- 
cided changes.  Here  its  continuity  w^as  broken  up  by  a  series  of  second- 
aiy  multiple  folds  having  a  vermiform  appearance  and  bridges  over  the 
superior  frontal  fissure,  which  was  obliterated.  In  certain  cases  of 
chronic  dementia  the  second  frontal  convolution  becomes  almost  rudi- 
mentary. The  third  frontal  con^'olution  (the  speech  center)  is  rarely 
modified,  except  when  there  is  aphasia.  Luys  has  found  in  tlu-ee  deaf- 
mutes  that  it  was  atrophied  upon  the  left  side. 

The  ascending  frontal  convolution  often  presents  a  change  in  its 
length  and  continuity.  At  its  union  Avith  the  second  frontal  we  find  nu- 
merous variations,  and  a  change  is  seen  at  the  origin  of  the  third  frontal. 
The  ascending  parietal  is  quite  rarely  alf  ected,  except  in  cases  AA-ith  para- 


ng. 13.— Brain  of  Microcephale  (Ireland), 
showing  the  imflnished  fissure  occipitalis  perpen- 
dicularis  externa,  the  parallel  fissure,  the  central 
fissure,  which  is  incomplete,  and  the  posterior 
branch  of  Sylvian  fissure,  a.  The  superior  frontal 
gyrus;  /j,  the  inferior  frontal  gyrus;  d,  anterior 
central  gyrus ;  f/',  posterior  central  gyrus ;  c,  pras- 
cuneus;  /,  lobulus  supra  marginalis;  f/,  gyrus 
angularis;  i",  cuneus;  p,  gyrus  temporalis  supe- 
rior; o,  gyrus  temporalis  medius. 


68  ^   SYSTEM   OF  LEGAL  MEDICINE. 

lytic  sjTnptoms.  The  angular  g^Tus  is  sometimes  affected  Avlien  there 
are  auditory  halluciuatious.  The  paracentral  lobule  is  often  the  seat 
of  pathological  changes,  on  one  side  or  both,  and  in  advanced  cases  of 
dementia  both  sides  will  be  affected. 

In  the  insane  it  will  be  found,  especially  in  forms  of  chi-onic  mania, 
or  where  there  has  been  excitement,  that  the  meninges  are  thickened, 
liyjiertemic,  or  that  there  are  heematoma?.  The  dura  mater  is  often  ad- 
herent to  the  skull,  and  the  other  membranes  show  e\adences  of  various 
grades  of  inflammation,  so  that  it  is  difficult  to  remove  the  arachnoid 
and  pia  mater  without  tearing  away  more  or  less  of  the  brain  sub- 
stance. Lesions  of  the  blood-vessels  may  be  found  which  vary  from 
simple  congestion  to  atheromatous  degeneration  or  permanent  dilata- 
tion, and  these  are  either  in  the  substance  of  the  meninges  or  in  the 
brain  itself. 

The  vascular  condition  of  the  brain  substance  is  either  one  of  hyper- 
semia  or  antemia.  Evidences  of  hypertemia  are  common  in  disease  at- 
tended with  excitement,  such  as  mania  or  dementia  paralytica.  The  gray 
substance  is  darker  and  the  white  is  more  pink  than  in  health.  Minute 
extravasations  or  local  tracts  of  active  congestion  are  found.  In  general 
2>aresis  these  spots  of  hypereemia  have  been  found  to  be  more  marked  in 
the  frontal  region,  though  in  this  disease  it  is  common  to  find  very  gen- 
eral congestion.  In  melanchoha  we  meet  with  a  pale  condition  of  the 
tissues,  with  diminished  caliber  of  vessels  and  perivasculai*  accumulation 
of  fluid,  and  the  brain  is  blanched  and  soft.  Territories  of  oedematous 
brain  are  found  in  association  mth  the  plugging  up  of  small  vessels  by  an 
embolus,  or  as  the  result  of  thrombosis.  There  may  be  bony  plates  in 
the  dura  mater,  wliich  are  very  common  in  chronic  insanity,  or  adven- 
titious substances  scattered  over  the  surface  of  the  brain,  both  at  the 
convexity  and  the  base.  The  brain  itself  presents  certain  changes  in  the 
appearance  of  its  convolutions  and  deeper  parts  which  are  quite  con- 
spicuous, and  softenmg  and  sclerosis,  gi^dng  rise  to  atrophy,  depression, 
and  changes  of  color. 

The  lining-membrane  of  the  ventricles  is  often  thickened  and  the  seat 
of  a  granular  change ;  and  an  accumulation  of  serous  fluid,  not  only  in 
these  ca\dties  but  in  the  meshes  of  the  arachnoid,  both  at  the  upper 
surface  and  at  the  base  of  the  brain,  is  present.  The  substance  of  the 
brain  may  be  the  seat  of  a  diffused  change,  there  being  small  collections 
of  indurated  tissue,  which  are  so  frequently  present  in  paretic  dementia. 
In  insanity  produced  by  alcohol  this  appearance  is  particularly  notice- 
able. In  other  cases  we  find  collections  of  gummatous  substance  pecul- 
iar to  syphilis.  In  still  others,  those  with  diseased  vessels,  there  are  one 
or  more  partially  organized  blood-clots,  and  perhaps  some  softening.  In 
many  brains  we  shall  find  a  condition  known  as  the  etaf  crible,  wliich 
consists  in  a  number  of  small  openings  giving  to  the  brain  a  porous 
appearance,  and  it  is  a  result  of  a  previous  hA"i:)era?mia  from  probable 
exudation  of  serum  and  atrophy.  It  is  rare  to  find  increase  in  size  of 
the  brain  as  an  indication  of  chronic  insanity — atrophy  is  much  more 
common.  Attention  may  be  called  to  the  thickening  of  the  cranial  bones 
in  chronic  insanity  and  the  existence  of  bony  spiculse.  Greding  presents 
21G  autopsies :  167  of  these  showed  thickening,  and  38  more  or  less  thin- 
ness of  the  bones. 


IXSAXITY  IX  ITS   MEDICO-LKGAL   BEAUlXiiS.  G9 

111  mchnirJioUd  Liiys  has  found  in  several  eases  ^veat  liyperaBmia  of 
the  gray  suljstanee  of  the  third  ventriele.  The  left  optie  thalamus  pre- 
sented on  its  internal  faee  hyix'ra'inie  redness,  wliieh  was  also  found  in 
the  third  ventriele.  The  gray  substanee  of  the  eortex  of  one  of  these 
patients  was  thin,  and  most  of  the  eonvolutions  appeared  of  a  pale  color, 
with  irregular  vaseular  arborizations  irregularly  disseminated.  It  seems 
to  l^e  a  peculiarity  of  this  form  of  disease  that  there  is  a  general  ischemia, 
with  localized  spots  of  liypeiu'inia.  In  some  cases  of  profound  inelanchoUa 
U'ith  stupor  the  1  train  was  found  to  l)e  completely  exsanguinated,  tlie  white 
sul)stance  deprived  of  ^'essels,  and  an  appearance  of  atrophy  of  the  cortex 
and  small  vascular  groups  was  presented  {des  petlts  honquda  vasculier  dis- 
poser  en  ilofs). 

In  cases  of  pari'tic  deniputia  excessive  and  abundant  proliferation  of 
the  nem'oglia,  with  choking  of  the  nerve  cells,  is  apparent,  the  latter 
being  diminished  in  number.  The  white  substance  as  well  as  the  gi'ay 
presents  the  same  appearance  of  sclerosis ;  the  nerve  fibers  appear  as 
withered  filaments,  and  are  torn  and  much  reduced  in  size ;  and  there 
nre  areohi?  which  indicate  the  disappearance  of  nervous  elements. 

Ill  aritte  mania  evidences  of  active  and  \nolent  hyj^era^mia  in  all  parts 
of  the  brain  are  found,  but  the  vessels  of  the  corpora  striata  are  most 
dilated  and  engorged,  and  the  white  substance  not  as  much  injected  as  the 
gray.  In  one  of  Luy's  cases  there  was  yellow^  coloration  of  the  insula, 
with  degeneration  of  all  the  nerve  elements  of  this  region.  In  another, 
an  old  foyer  of  softening,  occupying  the  center  of  the  pons,  was  found, 
the  w^alls  of  which  were  incrusted  with  coloring-matter,  gTanular  cor- 
puscles, and  crystals  of  ha'matoidin,  which  indicated  the  existence  of 
prolonged  congestion,  and  which  for  some  time  had  played  the  role  in 
this  region  of  a  pathological  point  of  irritation. 

The  causation  of  meningeal  inflammatiou  by  bacteria  has  recently 
been  fixed  to  a  certainty  by  several  observers.  In  acute  delirium  Rasori 
{GeniraJhlatt  fiir  BalxterioJogie,  etc.,  October  2,  1893,  quoted  by  Potts)  de- 
scribed a  bacillus  resembling  the  pneumonia  coccus,  and  quite  lately  Potts 
{Philadflpliia  Medical  JS'eivs,  Juue  30,  1894,  p.  718)  has  rei^orted  a  most 
•carefully  observed  case  which  ended  fatally.  The  temperature  reached 
108.2  just  before  death,  which  was  preceded  by  a  carbuncle,  and  later  by 
acute  delirium,  insomnia,  active  delusions  of  persecution,  and  hallucina- 
tions of  a  lively  nature  w4iich  were  chiefl}'  visual.  The  autopsy  was  made 
about  seventeen  hours  after  death.  The  brain  and  meninges  appeared  to 
be  normal,  as  were  all  the  other  organs  of  the  body.  Some  of  the  cere- 
bro-spiiial  fluid  that  had  drained  into  the  base  of  the  skull  was  collected 
in  a  small  bottle  previously  sterilized  with  boiling  w^ater,  and  from  this 
■cultures  were  made,  with  the  result  that  the  presence  of  a  bacillus,  an- 
swering to  the  description  of  the  so-called  Micrococcus  lanceolatus  or 
pneumonia  coccus  of  Fraenkel  and  Weichselbaum,  was  demonstrated. 
The  StaphijlococcKS  pjyogenes  aureus  and  the  Staphylococcus  pyoijenes  alhus 
were  also  present.* 

The  microscoi3ic  appearances  of  diseased  nervous  tissue  are  perhaps 

*  Microscopic  examination  of  the  cerebral  cortex  showed  the  appearances  described 
by  Osier,  i.e.,  perivascular  dilatatiou  aud  leucocj-tes  in  the  h-mpli  sheaths  aud  peri- 
gangliar  spaces. 


70  A   SYSTEM  OF  LEGAL  MEDICINE. 

of  greater  interest  than  any  others,  and  in  cases  where  no  grave  lesions 
are  presented  the  microscope  will  often  reveal  deUcate  changes,  which 
consist  most  commonly  in  degeneration  of  the  nerve  cells  of  the  cortex^ 
and  vascular  hyperaemia  and  its  consequences.  The  large  cells  of  the 
cortical  gray  substance  often  break  down,  and  leave  in  then*  places- 
collections  of  granular  matter,  which  may  be  either  found  in  isolated 
masses  or  the  cell  wall  may  be  intact  and  its  contents  entu-ely  disorgan- 
ized, there  being  disappearance  of  the  nuclear  elements.  (Plate  I.)  We 
shall  also  find  that  the  intercommunicating  fibers  and  nerve-cell  processes 
are  broken  off,  and  that  the  intercellular  connective  tissue  is  increased,, 
with  proliferation  of  the  nem-ogiia  cells,  and  perhaps  there  may  be  the 
appearance  of  amyloid  bodies.  The  blood-vessels  are  choked.  There  is 
exudation  of  coloring-matter  and  infiltration.  In  hypereemic  states  the- 
vessels  are  dilated,  their  Avails  being  covered  by  fat  granules  and  h^ma- 
toidin  crystals.  Sometimes  masses  of  pigment  are  found.  The  vessels 
are  varicose  or  disrupted,  and  the  perivascular  spaces  may  be  filled  with 
exudation  corpuscles.  The  nerve  cells  undergo  notable  changes  in  dis- 
ease. It  has  been  found  that  in  cases  of  insanity  with  hallucination  they 
are  greatly  increased  in  size,  and  Meschede  has  found  in  paretic  dementia 
that  the  increase  is  very  decided.  Luys,  on  the  other  hand,  has  found  a 
reduction  of  the  cells  in  paretic  dementia,  as  well  as  a  diminution  in  their 
number.  In  some  brains  we  find  small  vacuoles,  others  than  those  due 
to  congestion,  scattered  through  the  brain  substance,  which,  however,  are 
more  often  the  result  of  careless  manipulation  than  of  a  pathological 
process. 

In  this  connection  a  word  of  caution  is  necessary,  for  it  is  a  very  easy 
matter,  through  improper  hardening  or  incautious  staining,  to  so  alter 
the  arrangement  and  character  of  the  anatomical  elements  as  to  produce 
appearances  in  every  respect  resembling  those  of  actual  disease.  Hard- 
ening in  alcohol  is  quite  likely,  unless  great  care  be  used,  to  have  this 
result,  and  sometimes  carmine-staining  with  a  badly  prepared  solution 
will  give  granular  changes  which  are  very  confusing.  In  hardening  the 
brain,  especially  where  medico-legal  questions  are  involved,  we  must  fre- 
quently change  the  fluid,  protect  it  from  dust,  and  conduct  our  manipu- 
lations in  a  systematic  and  careful  manner ;  and  it  is  weU  to  have  our 
observations  confirmed  by  another  person. 


Physical  Signs  of  Insanity. 

The  external  evidences  of  existing  mental  disease  are  iisually  more 
or  less  pronounced.  The  objective  evidences  in  cases  in  which  arrested 
brain  development  exists  are  varied  and  characteristic,  consisting  mainly 
in  asymmetry  of  the  head,  the  cranium,  and  face ;  a  misshapen  frame, 
club-foot,  a,s  well  as  trophic  defects  of  various  kinds.  These  blights  may- 
be recognized  at  an  early  age  or  do  not  develop  until  later.  Clouston 
aptly  says :  "  It  is  a  truism  that  each  age  has  its  own  lieauty ;  it  is  equally 
true  that  each  age  has  its  own  deformity.  A  beautiful  child  may  become 
an  unprepossessing  youth,  because,  through  hereditary  influences,  the 
development  of  the  countenance,  the  form,  and  the  movements  has  not 


PLATE   I. 


i^ii?..i 


X     300 


Fig.  J 


X     650 

^Mifi'o.scoijic  ai)pcai'aiue  of  brain  of  epileptic  dement,  sbovvinK  cellular  degeneration. 

(Cloiistou.) 


Fi^.  1.— c(.  Nerve  cell  showing  well-,stained  nucleus,  with  small  amount  of  protoplasm 
round  it ;  />,  nerve  cell  showing  remains  of  apex  process  and  granules  of  pigment  in  pnjtoplasin  : 
(\  mass  of  cell  protoplasm  without  nucleus;  r(,  nucleus  of  nerve  cell,  apparently  destitute  of 
protoplasm  ;  r;,  nucleus  of  neui-oglia  cell.     (X  300.) 

Fig.  2.—A  nerve  cell  showing  granular  condition  of  protoplasm,  collections  of  pigment 
granules,  irregular  staining  of  nuc'leus,  and  atrophy  of  protopla.sm  and  processes.     (X  6.")0.) 

71      72 


INSANITY  IN  ITS   MEDICO-LEGAL  BEARINGS. 


73 


p^one  on  tlie  lines  tliat  make  for  mature  l)eauty.  There  has  been  a  lack 
of  harmonious  progress;  the  bodily  ideal  of  the  age  of  adolescence  has 
not  been  attained,  through  the  working  of  an  evil  heredity.  Some  feat- 
ures have  been  retarded  in  growth,  some  distorted,  some  overgrown. 
It  is  beyond  a  doubt  in  families  with  neurotic  hereditary  taint  that  we 
find  marked  ugliness,  asymmetry,  dwarfishness,  hunehljack,  scjuint,  un- 
gainly movements,  hoarse  laughing,  lioljbledehoyism,  uncomfortable 
limbs,  and  such  like  departures  from  the  anatomical  and  physiological 
ideal." 

By  far  the  most  suggestive  index  of  the  insane  temperament  is  the 
misshapen  head.  While  a  large  number  of  insane  persons  have  the  long 
or  dolklioceplialic  head,  such  a  cranial  peculiarity  has  not  the  suggestive- 
uess  of  one  of  a  rhomboidal  type,  or  when  the  two  sides  are  asymmetri- 
cal, but  at  best  such  appearances  are  only  indices  and  not  proofs  of 
mental  weakness.  The  teeth  of  imbeciles  are  uneven,  the  incisors  being 
sometimes  crenated;  the  ears  are  misshapen  or  irregular,  contain  the 
Darwinian  tubercule,  and  are  satyr-shaped  or  abnormally  large  or  small. 
Hypermetropia  is  common.  The  finger-ends  are  expanded  and  the  move- 
ments of  the  body  indolent. 

The  appearance  and  conduct  of  an  insane  person  of  course  depend 
very  much  upon  his  form  of  disease,  as  well  as  its  stage  and  duration. 
It  is  always  possible  to  witness  a  radical  and  progressive  alteration  in 
cases  that  have  become  chronic,  a  physical  change  keeping  pace  with  the 
niBntal  deterioration.  Women  who  have  been  comely  become  ugly. 
E  i^ression  alters,  the  lines  of  the  forehead  and  lower  part  of  the  face 
b(  eoming  deepened,  and  the  dominant  affective  feeling  leaving  its  im- 
p]  ess.  The  facial  furrows  that  form  are  referred  to  by  many  as  im- 
p  rtant  diagnostic  nuirks  in  chronic  insanity,  especially  the  depressed 
C(  nditions  such  as  hypochondriacal  insanity  and  melancholia.  In  the 
latter  there  may  be  a  distinct  transverse  furrow,  which  sometimes  extends 
across  the  entire  forehead  or 
is  again  unilateral,  appear- 
ing over  one  eye.  Through 
contraction  of  the  frontal 
muscles,  the  corrugator  su- 
percilii,  horizontal  folds  of 
the  forehead  and  deep  ver- 
tical folds  extending  up- 
ward from  the  root  of  the 
nose  are  produced.  (Fig.  14. ) 
As  a  result  of  the  persistent 
and  constant  contraction  of 
other  muscles,  we  find  droop- 
ing of  the  lower  lip  and  re- 
laxation of  the  nmscles  at 
the  side  of  the  face.  In 
mania  and  other  elated  con- 
ditions there  are  no  constant 

traces  left  except  in  chronic  states,  but  the  muscles  being  in  lively  play 
the  experience  is  one  of  pleasure  and  jo,y,  or  anger  and  excitenumt. 
Through  trophic  changes  and  muscular  atony  we  find  that  the  features 


74  A   SYSTEM   OF  LEGAL  MEDICIXE. 

lose  tlieir  cliaraeter,  the  furrows  disappearing,  and  the  mouth  becoming- 
changed  in  mobility.  Blankness  eventually  comes,  with  mental  vacuity. 
(Fig.  15.)     Tlie  attitude,  gestures,  locomotion,  all  undergo  changes,  and 

the  speech  is  hesitating,  ex- 
plosive, and  embarrassed, 
or  the  subject  indulges  in 
ve)i)ige)'afio)i,  which  consists 
in  the  repetition  of  words  in 
an  irrelevant  way,  so  that 
the  resultant  effect  is  a  ro- 
domontade of  a  meaningless 
kind.  New  words  are  coined, 
and  syllables  joined  incon- 
gruousl}',  so  that  the  result 
is  a  compound  creation 
which  usually  conveys  a 
liombastic  hint  of  the  pa- 
tient's grandiose  delusions. 
The  formation  of  new^  words 
Fig.  15.  is  often  the  result  of  hallu- 

cination or  delusion.  In  the 
first  case  the  distorted  percepts  and  absurd  concepts  which  usually  spring 
from  auditory  hallucinations  lead  the  patient  to  put  into  words  the  things 
he  imagines  he  hears.  The  words  used  are  often  most  distorted  and  con- 
fused, and  not  only  consist  of  those  of  his  own  language,  but  combined 
words  made  by  the  conjunction  of  syllables  from  some  foreign  word  with 
one  of  Ms  own  tongue.  There  is  in  excited  and  confused  patients  a  ten- 
dency to  indulge  in  phrases  that  have  a  mj^stic  significance.  Sometimes 
a  repeated  distortion  of  a  syllable  wiU  be  persisted  in.  One  of  my  patients 
in  a  conversation  of  a  few  minutes  used  the  word  "came"  for  "come," 
"becase"  for  "because,"  etc.,  at  least  a  dozen  times.  EcliolaJia  is  a  term 
apphed  to  the  form  of  speech  in  Avhich  the  last  syllable  of  words  heard 
or  the  last  word  articulated  by  the  patient  himself  is  repeated. 

The  letters  of  the  patient  ordinarily  convey  the  best  idea  of  his  con- 
fusion, even  when  he  is  on  his  guard  in  other  ways,  and  I  append  the 
production  of  an  insane  subject,  which  illustrates  a  form  of  phrase  repe- 
tition and  extravagance  of  fantastic  w^ord  use  which  cln-onic  patients 
so  often  indulge  in.  This  paranoiac  patient  thus  describes  a  flag  she  has 
designed : 

CHURCH   SUNDAY  SCHOOL  AND   STATE   BANNER  OF   THE   UNITED   STATES  OP   MINNEHAHA 

AND    COLUMBIA. 

Ordinarily  quite  Large  White  Silk  for  the  wliole  of  the  background  of  Church 
Banner  and  a  tinge  off  into  blue  as  dark  as  jjerfect  taste  would  allow  for  State  Banner 
of  United  States  of  Minnehaha  and  Columbia  including  Mary  Fidelia  Bourne  Stellar 
or  Planetary  Universe. 

State  Flag  of  the  United  States  near  the  top  with  either  the  full  number  of  States 
and  Territories  or  tlie  Original  Thirteen  Meaning  twelve  originally  ours  and  one  gi'eat 
Cruelty  M'e  adopt  to  protect  in  full  natural  color  with  Abraham  Lincoln  holding  under- 
neath the  Motto  Malice  toward  none  Cliarity  for  all.  And  tlie  Holy  Dove  above.  Be- 
low on  the  Eight  Side  an  Orange  Tree  in  full  Bloom  and  delicate  fruit  in  natural  color 
with  Justice  written  upon  it.  In  the  center  lower  than  tojj  of  Orange  tree  a  group 
of  figures  in  whatever  color  perfect  taste  orders  an  American  or  Hebrew  Cross  with 
Lilies  of  the  Valley  and  ordinary  Espiritu  Santo  twining  over  it  and  perliaps  grape 


IXSANITY  ly  ITS  MEDICO-LEGAL  BEARINGS. 


75 


vine  and  by  me  hold  by  me  as  Goddess  of  Liberty  and  America  Benevolence  and  Truth 
■written  upon  it  at  lier  feet  comin<,'  up  perhaps  as  far  a«  the  knees  agi-icultiiral  instru- 
ment with  grapes  in  bloom  or  fruit  over  it  on  each  side  two  well-known  ^Monarch  with 
■weapons  of  defusive  warfare  and  work  One  and  Aiistaradat  as  Peter  Bowne  the  Groat 
of  Russia  who  no  menial  service  honestly  and  noble  peii'ormer  wrong  for  the  highest 
dignity  to  do  he  over  the  right  with  a  well  known  face  Then  on  the  left  of  Goddess  of 
Liberty  and  America  Charles  the  5tli  of  Twelth  of  Spain  Conqueror  of  the  Netherlands 
Prescott  has  a  memoir  highly  interesting  of  him  a  Thorough  penitent  with  a  well 
known  face  and  ten  Coranumdents  in  tablet  form  in  Instrument  of  Agriculture  with 
Laborore  et  Ovare  and  Return  for  Evil  together  Underneath  Orange  and  Peach  tree,  z, 
number  of  Irregular  Lumps  of  Dirt  and  Stone  with  Tiger  Lily  very  beautifid  and 
Dandelions  and  jealousy  grass  at  the  bottonr  over  Lumj)  of  Dirt  t^vo  skeltons  Hands 
with  know  number  of  Stoned  unjustly  in  America  or  its  Representation  to  please 
Cruelty  who  were  Cosmopolitans  Aristocrats  chiefly  from  British  India  and  knowing 
heathendom  practically  many  did  not  wish  to  be  redeem  back  to  it  nor  to  mention 
Jesus  name  after  as  it  brought  a  bad  fate  or  to  know  the  private  affairs  of  Gods  or 
Goddess  and  wished  to  be  impartial  for  that  reason  were  probably  starved  by  the  cruel 
Creation  a  number  of  Friends  of  Goddess  of  Liberty  or  America  being  among  the  num- 
ber several  private  friends  all  her  political  ones  who  loved  to  hear  the  Truth  as  the 
Spirit  of  Truth  of  Truth  Through  Catholic  Aposlitic  or  Methodist  Episcopal  declared 
it.     In  its  purity  and  truth. 

On  the  lefthand  side  of  group  as  high  as  Orange  a  Missippi  Peach  in  full  bloom 
and  delicate  fruit  natural  Color  on  it  Mercy  written. 

Written  in  Lumps  of  Dirt  and  Stone  Cruelty  Selfishness  Wrong  Ingratitude  False- 
hood Treachery  Kindness  in  prosperity,  unkindness  in  adversity  or  False  Friendliness. 
Meanness  Uncleanness  Lust  or  Cruelty  Selfishness  Ingratitude  TjTanny  Error  False- 
hood Treachery  Kindness  in  prosperity  unkindness  in  adversity  Uncleanness  Lust. 

At  the  bottom  imderneath  Jealousy  grass  and  dandelion  the  Words  Faith  Hoj)e 
and  Charity  on  State  Banner  with  perhaps  the  passage  of  Scripture. 

As  I  live  south  the  Lord  God  I  have  no  pleasure  in  the  Death  of  the  Wicked  but 
rather  that  He  may  turn  from  his  wickedness  and  live  tm'n  ye  turn  ye  for  why  will 
ye  die. 


D 


f^JHSyO    K^^^JU\kIJJ^xO 


iJbijf 


hur-l--^^ 


/AA-./0-S^XAA-/o^^,^ 


juA^ 


M-^^-yiy-xjJ  ^ 


Fig.  16. — Writing  of  a  paranoiac. 

The  handwriting  itself  underg-oes  a  decided  change  in  character,  aud 
is  often  feeble  and  uncertain  or  else  suggests  an  exaggerated  vigor  aud 
nervous  force  resulting  in  the  production  of  bizarre  scrolls,  markings,  aud 
interlineations.    (Fig.  16.)    Of  coui'se  the  disposition  to  write  varies  ■with 


76  ^   SYSTEM  OF  LEGAL  MEDICINE. 

the  diseased  mental  activity,  those  who  are  atonic  or  demented,  writing 
but  little,  while  the  victim  of  chronic  mania  has  a  veritable  cacoatlies  scri- 
dendi.  This  is  especially  the  case  in  paranoia,  the  person  of  one  idea  filling 
pages  with  diagrams,  sketches,  and  sjanbolic  references,  often  of  a  mathe- 
matical or  religions  character.  One  of  the  best  cases  of  this  kind  is  that 
of  a  Mr.  B.,  an  artist,  sent  by  me  to  Bloomingdale,  where  his  extraordi- 
nary ideas  found  expression  in  exquisitely  executed  illustrations  which 
have  been  collected  and  published  by  Dr.  Noyes. 

/tT^C^-i^  yy'€».^€^cL  ^^«&.  /55»^  tf^^  ^<^y^ 

tM^^--€!ia.i^u^  Gf.^^  J^i^  "^z^^^z^^^ 

Fig.  17. — Writing  of  an  educated  paretic  dement;  advanced  stage. 

In  paralytic  dementia  and  other  insanities  where  there  is  mental  weak- 
ness and  lack  of  attention,  it  is  common  to  find  words  omitted  or  unfin- 
ished, as  well  as  tremor  and  irregularity ;  and  specimens  taken  at  different 
times,  when  compared,  show  the  degeneration  very  beautifully.  (Figs. 
17  and  18.) 

The  attitude  of  the  lunatic  is  as  a  rule  largely  determined  by  the 
nature  of  his  hallucinations,  should  thej^  be  present,  and  he  changes  liis 
position  and  behaves  in  a  measure  as  he  would  if  the  impressions  he  re- 
ceived were  real.  Should  he  be  the  suljject  of  one  of  the  exalted  kinds 
of  mental  disease,  he  shows  it  by  his  excited  manner,  flushed  face,  bright 
eyes,  quick  play  of  features,  bristly  hair,  quick  speech,  and  restlessness ; 
while  the  reverse  is  true  of  atonic  melancholia,  where  inaction  character- 
izes the  condition.  The  patient  is  listless,  taciturn,  absorbed,  and  will 
not  usually  move  unless  stimulated  and  urged.  When  anxiety  is  a  feat- 
ure we  are  presented  Avith  the  expression  we  would  find  in  a  normal 
condition,  only  intensified. 


r 


^Z^^yzA^^ 


/ 


Fig.  18. 

Writing  sliowing  deterioration  in  paretic  dementia.   (Bacon.) 

o,  b,  Writing  of  educated  man,  with  interval  of  several  months;  c,  (7,  writing  of  nnedu- 
cated  man  with  commencing  paretic  dementia,  c  being  written  soon  after  admission  to  asy- 
lum, and  d  his  writing  in  health. 


78 


A   SYSTEM  OF  LEGAL  MEDICINE. 


Tlie  existence  of  delusions  is  often  reflected  in  dress,  and  in  asylums 
one  or  two  patients  are  iisually  shown  wlio  decorate  themselves  with 
all  the  bits  of  bright  metal  and  gay  colors  they  can  find.  This  kind  of 
adornment  is  usually  associated  Avith  unsj^stematized  delusions  of  power, 
the  patient  believing  himself  to  be  a  potentate. 

The  Ear. — Attention  has  been  called  to  the  misshapen  ear,  which  is 
likely  to  be  an  index  of  a  prolonged  degenerate  condition.  There  is  an- 
other deformity  of  the  ear  belonging  to  chronic  insanity,  and  this  con- 
sists in  a  striking  deformity  due  at  first  to  impaired  function  of  the 
sympathetic  fibers  and  a  low  condition  of  vitality  of  the  organ,  and  to 
subsequent  injury  and  inflammation  and  ultimate  contraction,  so  that 
there  is  a  residtant  change  in  shape  and  size  which  is  conspicuous. 
While  the  ear  is  congested,  as  is  often  the  case  in  chi'onic  insanity,  it  is 
liable  to  be  injured  or  bruised,  and  laceration  of  small  blood-vessels  oc- 
curs, followed  by  extravasation.  The  condition  is  known  as  othcematoma, 
or  the  "insane  ear."     Othfematoma  may  be  associated  with  nearlj^-  every 

form  of  chronic  insanity,  and  is  usually  of 
---     --<^-  grave  omen  so  far  as  complete  recovery  is 

concerned.  (Fig.  19.)  Through  constant  pull- 
ing or  tugging  upon  the  part  of  the  patient, 
even  though  the  above  condition  may  not 
exist,  the  ear  often  undergoes  a  distortion. 

TJie  Eye. — The  pupils  constantly  present 
changes  or  inequalities  that  are  suggestive 
and  valuable  in  verifying  other  indications 
of  disease  of  the  brain.  In  organic  insani- 
ties, especially  paretic  dementia,  there  is  at 
times  iinequal  dilatation,  or  symmetrical  con- 
traction or  dilatation.  In  paretic  dementia 
there  is  often  pupilary  action  with  accom- 
modation but  not  with  light  stimulation.  In 
mania  they  are  usually  contracted,  in  melan- 
cholia of  all  forms  dilated.  The  dilated, 
mobile  pupil  of  the  epileptic  is  present  in 
about  halt  the  cases.  In  insanities  due  to 
coarse  brain  disease,  or  in  alcoholic  insanity, 
it  is  not  unusual  to  find  paralysis  of  the  motor  apparatus  of  the  eye,  as 
well  as  atrophy  and  disease  of  the  fundus  oculi. 

The  muscular  condition  of  the  insane  is  sometimes  significant,  especially 
when  the  disturbances  of  motility  consist  in  fine  tremors,  which  indicate 
a  lowered  muscular  tone.  These  may  best  be  witnessed  in  the  muscles 
of  the  face,  tongue,  and  hands  in  paretic  dementia.  Convulsions,  ataxia, 
and  certain  automatic  movements  are  prominent  diagnostic  signs  of  cer- 
tain insanities  mth  distinct  organic  causation,  such  as  the  sj^hilitic  and 
alcoholic  psychoses.  The  tendinous  reflexes  are  as  a  rule  increased  in 
insanities  where  mental  inhibition  is  suspended,  and  in  such  degener- 
ative affections  as  paretic  dementia  they  are  more  active,  or,  on  the  con- 
trary, absolutely  gone. 

Cutaneous  AncBsthesia. — Lowered  cutaneous  sensibility  is  highly  char- 
acteristic of  stupid  or  demented  states,  or  forms  the  basis  of  delusions 
and  hallucinations  in  the  manner  elsewhere  described.  It  is  undoubt- 
edly due  at  times  to  autohypnotism,  which  is  associated  mth  those  qui- 


Fig.  19. 


ixsjy/ry  ix  jt.s  mjjdico-ijjgal  lUJ.iL'iya.'^.  7<j 

escent  states  of  will  feebleness.  Kirelilioff  saj's :  ''  If  there  is  very  exten- 
sive diminution  of  sensibility  the  patient's  feelin<f  of  his  own  personality 
may  be  extin<iuishe(l  and  lie  may  believe  himself  dead.  If  the  ana-s- 
tliesia  is  confined  to  certain  vis(;era — for  example,  if  tlie  inj^estion  of 
food  takes  place  witliout  feelin<^ — the  patient  believes  that  he  has  no 
stomach." 

The  scrrcfioit  of  team  is  diniinish(.'d  in  melancholia,  but  is  abundant 
in  i)aretic  dementia  and  is  apparently  in  no  way  connected  with  mental 
sufferinii:,  the  tears  flowing-  with  the  least  excitement. 

Tlie  skin  of  the  insane  is  apt  to  be  dry  and  harsh,  especially  in  the 
depressed  forms ;  but  tliis  is  not  necessarily  a  feature  of  all  insanities,  as 
it  is  claimed.  The  violent  muscular  action  incident  to  mania  gives  I'ise 
usually  to  profuse  sweating.  The  writer  has  witnessed  an  oily  condition 
of  the  skin  in  adolescent  and  evolutional  insanities. 

The  fenq)er((fHre  in  melancholia  and  dementia  is,  as  a  rule,  lowered ; 
the  surface  temperature,  esj^ecially,  is  reduced,  so  that  the  skin  is  cool 
and  clammy,  and  through  sluggishness  of  cii'culation  is  pale,  dusky,  or 
mottled.  The  subnormal  temperature  may  be  as  low  as  96.5°  or  less.  In 
mania  and  other  excited  states  the  temperature  does  not  rise,  except  when 
there  is  the  condition  known  as  typhonuxnia,  in  which  delirium  is  present. 
In  stuj^orous  insanity  and  the  apathetic  forms,  where  great  exhaustion 
exists,  its  extreme  reduction  usually  foreshadows  a  fatal  termination. 

Digestion  and  appetite  are  likely  to  be  more  or  less  deranged  in  every 
form  of  acute  insanity,  but  in  mental  disease  of  long  standing  the  ajij^e- 
tite  and  digestion  are  entirely  unaffected.  In  melancholia  there  is  a 
history  of  indigestion  and  defective  assimilation — the  urine  is  usually 
loaded  with  urates,  except  in  cases  where  its  secretion  is  abundant — the 
atonic  examples.  These  patients  often  suffer  from  diarrhoea  and  the 
passage  of  undigested  food,  which  symptomatize  the  insufficiency  of 
mastication.  Constipation  associated  with  tympanites  belongs  to  the 
hypochondriacal  variety  of  melancholia,  and  the  fecal  matter  is  deficient 
in  biliary  coloring  matter.  The  ravenous  appetite  of  mania  is  largely 
psychical  and  not  due  to  any  actual  craving  for  food.  In  hysterical  and 
puerperal  subjects  there  is  also  an  evidence  of  mental  degeneration 
which  consists  in  the  craving  for  nauseous  and  indigestible  substances. 
In  paretic  and  other  forms  of  dementia  the  patient  is  apt  to  eat  too  has- 
tily, thus  producing  gastric  disorders ;  or  he  may,  through  paralysis  of 
the  pharyngeal  muscles  and  anaesthesia  of  the  epiglottis  and  upper  part 
of  the  larynx,  be  asphyxiated  by  the  lodgment  of  a  bolus  of  food  or  jnece 
of  meat  in  the  latter. 

Tvophir  disorders  are  likely  to  ensue  in  cases  that  have  existed  for 
an  extended  length  of  time.  Cutaneous  alterations,  such  as  deposits  of 
pigment,  staining,  changes  in  the  growth  and  color  of  the  haii',  herpetic 
and  other  eruptions,  are  among  these,  as  well  as  brittleness  of  the  bones, 
fractures  being  very  common  among  the  chronic  insane.  Bed-sores 
usually  attend  the  last  stages  of  protracted  insanity,  and  are  common 
among  dements  or  those  who  have  undergone  very  great  exhaustion. 

IVte  nrine  of  the  insane  may  present  the  ordinary  evidence  of  liodily 
waste,  especially  in  mania  or  psychoses  where  great  wear  and  tear  exists. 
In  agitated  conditions  the  quantity  of  urea  is  inin-eased,  and  after  epileptic 
paroxysms  it  has  been  found  to  contain  albumin  and  even  sugar.  Some 
years  ago  the  writer  conducted  a  series  of  experiments  at  the  Hudson 


80  -4   SYSTEM  OF  LEGAL  MEDICINE. 

River  Hospital  for  tlie  Insane,  wLicli  disclosed  the  fact  tliat  tlie  appear- 
ance of  sng'ar  in  the  nrine  of  paralytic  dements  was  to  be  looked  for  at 
some  time  or  other  in  most  cases.  Its  presence  has  been  detected  in 
periodical  mania.  In  alcoholic  insanity  it  is  qnite  natnral  to  look  not 
only  for  casts  and  other  evidences  of  renal  disease,  but  albnmin  as  well. 
These  evidences  of  increased  blood-pressnre  in  connection  with  acute 
states  are  found  not  only  after  attacks  of  mania,  but  after  the  convul- 
sions occurring  in  the  com'se  of  paretic  dementia. 


The  Insanities. 

I.   IDIOCY. 

This  term,  as  here  used,  impHes  a  congenital  defect  in  both  mental 
and  physical  development,  and  differs  from  imbecility  ("  acquired  idiocy" 
of  some  writers)  in  the  fact  that  such  defects,  whatever  they  may  be,  are 
j)renatal,  and  are  due  to  causes  which  act  directly  through  the  parents. 
Injury  inflicted  during  delivery — from  forceps,  pressure,  and  the  like  be- 
ing exceptions — for  the  true  idiot  possesses  purely  atypical  defects  due 
to  defective  organization. 

The  remote  influences  causing  the  anomalies  of  development  that 
belong  to  a  feeble  child  of  this  kind  are  more  apt  to  be  alcoholism  and 
syphilis  than  any  others,  although  sensitive  people  who  desire  to  find  a 
less  degrading  explanation  are  prone  to  assign  the  weaknesses  of  theu"  off- 
spring to  such  ti-aumatisms  as  falls,  the  carelessness  of  nurses,  or  actual 
injury  inflicted  by  the  forceps  duiiug  delivery.  Such  causes  are  compar- 
atively unusual,  as  the  study  of  the  physical  aspects  of  the  disease  will 
prove. 

Idiocy  is  due  much  more  often  to  the  intemperance  of  the  progenitors 
than  to  any  other  cause.  Of  359  idiots  seen  by  Dr.  Howe,  it  was  found 
that  in  99  cases  the  parents  were  confii-med  drunkards.  Consanguineous 
mariiages  are  believed  by  Maudsley  to  lead  more  often  than  is  generally 
supposed  to  degeneracy,  which  is  manifested  in  succeeding  generations 
by  idiocy.  Exactty  how  much  syphilis  predisposes  to  this  condition  it  is 
difficult  to  say,  for  its  manifestations  are  ii-regular.  Not  onh'  can  it 
result  in  late  forms  of  degeneracy — in  infantile  general  paresis,  as  has 
been  witnessed  by  C^louston — but  it  is  ordinarily  behind  congenital 
feeble-mindedness,  with  associated  epilepsy. 

The  pliysical  peculiarities  of  idiots  are  varied  and  striking.  The  con- 
figuration of  the  cranium  is  one  of  these,  and  Broca  has  described  several 
varieties,  the  most  important  of  which  is  the  microcepliaJons  head.  The 
diminutive  head  may  have  a  circumference  of  but  thirteen  inches,  and 
an  exceedingly  great  facial  angle.  Broca  holds  that  the  possessor  of  a 
skull  with  an  anteroposterior  diameter  of  148  millimeters  is  a  micro- 
cephale.  Of  the  two  principal  varieties,  the  dwarfed  idiot  and  the  idiot  of 
ordinary  height  {Jcs  nai)is  ct  Ics  iixJiridiis  de  i<tille  ordinaire)^  the  latter  are 
almost  always  deprived  of  th(^  faculty  of  language — sometimes  they  can 
pronounce  a  few  words,  without  any  appreciation  of  what  is  meant ;  the 
cranium  is  hirger  than  that  of  the  first  variety,  and  may  be  140  to  145 
millimeters  in  length,  with  possibly  a  circumference  of  420  to  425  milli- 
meters and  a  capacity  of  from  GOO  to  700  cubic  ceaitimeters. 


INSANITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  81 

The  greater  number  of  microcephalous  idiots  are  of  the  first  variety 
{dwarfs)  and  rar(4y  i>'r()vv  taller  than  a  boy  of  eight  yeai-s.  (Broca.)  IMany 
always  remain  nndevelopt'd,  others  are  taught  to  talk,  and  l)ut  few  ad- 
vance beyond  the  mental  status  of  a  child  of  two  years.  The  antero- 
posterior dianu^ter  of  the  skidl  may  be  no  more  than  over  10  to  13  centi- 
meters, the  horizontal  cir(nimference  may  bo  from  32  to  37  centimeters, 
and  the  capacity  is  alwa3^s  below  GOO,  and  may  be  no  more  than  300 
<3ubic  centimeters.  The  case  of  the  microcephale  John  Rouse  is  one  well 
known  in  psychiatrical  literature.  He  was  under  my  care  for  several 
years,  and  as  a  microcephale  ranks  with  the  eases  reported  by  Ireland. 
•John  Rouse  is  a))out  fifty,  weighs  72  pounds,  is  4  feet  7^  inches  high. 
The  circumference  of  the  head,  taken  at  a  j)oint  one  inch  above  the  root 
of  the  nose  anteriorly  and  the  occipital  protuberance  posteriori}',  is  15 
inches.  The  biaural  arc  is  8  inches,  and  the  anteroposterior  arc  is  8 
inches.  These  measurements  must  be  reduced  about  an  inch  hy  reason 
of  the  existence  of  thick,  coarse  hair.  His  teeth  have  disappeared,  and 
he  has  a  double  cataract.  The  left  ear  is  the  seat  of  a  hematoma.  His 
intellect  is  almost  nil.  He  can  only  say  a  few  words,  without  any  idea 
of  their  meaning.  Broca  also  describes  the  demi-microeephale.  Very 
•often  weak-minded  children  of  this  kind  present  no  diminution  in  the 
size  of  their  crania ;  in  fact,  I  think  the  majority  of  my  own  cases  were 
the  possessors  of  unusually  large  heads.  The  scapliocephalons  deformity 
consists  of  an  exaggeration  of  the  vertical  and  longitudinal  diameters ; 
the  plagiocepliahus  or  obhque-oval  deformity,  depends  upon  premature 
obliteration  of  one  of  the  branches  of  the  coronal  suture  and  of  the  lamb- 
doidal  suture.  In  the  jjlafijcephalous  deformity  the  sinciput  is  flattened 
•and  the  vertical  diameter  is  diminished ;  in  the  acrocephalous  head,  on 
the  contrary,  the  sinciput  is  conical  and  there  is  an  increase  in  the  ver- 
tical diameter. 

Indication  of  prematui*e  closing  of  the  sutures  is  often  present,  and 
.should  be  looked  for.  The  height  of  the  palatal  arch  has  been  referred 
to,  and  an  increase  with  basal  narrowing  is  regarded  by  most  authors  as 
.an  invariable  sign  of  defective  development.  I  present  an  excellent 
plate  of  Clouston,  which  enables  the  reader  to  compare  several  t}T3es  of 
mouth-roof — the  normal,  the  neurotic,  and  the  deformed.  The  mouth 
of  the  idiot  is  large,  and  the  lips  coarse  and  full ;  the  teeth  are  une\'en 
or  in  a  double  row,  and  perhaps  connected  with  fissin-ing  of  the  hard 
palate ;  harelip,  or  that  projection  of  the  lower  jaw  known  as  progiiafJiisni, 
may  be  present,  and  when  it  is,  is  highly  characteristic.  The  features  of 
the  idiot  are  coarse.  His  vision  is  defective  or  he  may  be  actually  l)Iind, 
or  he  is  apt  to  suffer  from  disease  not  only  of  the  eyeball  itself,  but  its 
muscles  as  well,  so  that  there  may  be  atrophy  of  the  disk,  cataract,  or 
strabismus,  and  there  is  an  inability  to  fix  the  e3^e  upon  small  objects. 
The  hair  upon  the  body  is  sometimes  coarse  and  plentiful,  or,  on  the 
other  hand,  is  unusually  fine  and  silky,  though  this  latter  condition  of 
affairs  is,  I  think,  more  marked  in  imbecility.  Idiots  are  slow  and  awk- 
ward in  their  movements,  disinclined  to  Avork,  as  the  niuscular  SA'stem  is 
weak.  Cutaneous  sensibility  may  be  either  elevated  or  depressed ;  in 
the  latter  case  there  is  a  remarkable  t(^leranee  of  external  disagrei-able 
irritation.  Sometimes  there  is  loss  of  smell.  The  gait  is  often  waddling 
and  unsteady,  and  the  grasp  weak.  His  habits  are  untidy  and  dis- 
gusting; he  gorges  himself  with  whatever  may  be  placed  before  him, 


A  SYSTEM  OF  LEGAL  MEDICINE. 


SECTIONS  OF   STANDARD   PALATES. 


TY PICA  Li 


NEUROTIC. 


DEFORMED 


TRANSVERSE, 


LONGITUDINAL. 


The  Soft  Palate  Is  represented  by  &  dotted  line* 

Fig.  20.— Casts  of  vault  of  mouth  showing  defects  in  hard  palate.    (Clouston.>' 


7.  TYPICAL. 


3.  DEFORMED, 


2?^-v 


4.  NEUROTIC. 


5.  DEFORMED. 


6.  DEFORMED 
with  Central  Ridge> 


EXTREMELY  DEFORMED  PALATES. 


Fig.  21. 


Casts  of  palates,  showing  standard  types  on  left,  and  changes  found  in  adolescent  insanity  on 

right.    (Clouston.) 

83 


84  A   SYSTEM  OF  LEGAL  MEDICINE. 

and  often  carries,  for  lioiu'S  at  a  time,  in  liis  mouth  a  Ijolns  of  food.  He- 
voids  his  urine  and  faeces  wherever  he  maj^  be,  and  veiy  often  indulges  in 
mastm-bation  and  objectionable  amusements  of  a  "vile  character. 

The  idiot  is  either  non  compos,  or  his  capacity  is,  as  Pinel  has  observed^ 
below  that  of  another  jjerson  of  his  own  age.  In  some  cases  the  intelli- 
gence is  even  upon  a  par  with  that  of  some  of  the  lower  animals,  and 
mental  expression  is  chiefly  emotional.  He  manifests  feeble  degrees  of 
pleasiu-e  when  shown  bright  objects,  and  indulges  in  fitful  and  short- 
lived gusts  of  passion  without  cause.  He  delights  in  rhythmical,  musical 
sounds,  or  to  indulge  in  automatic  movements.  His  instincts  are  animal ; 
and  without  the  restraint  of  judgment  he  gratifies  ever}^  appetite,  how- 
ever low.  In  completely  idiotic  persons  there  is  no  sign  of  recognition,, 
no  indication  of  memoiy,  and  the  intellectual  capacity  is  rudimentary. 
There  is  the  absence  of  the  piimary  mental  apparatus,  the  absence  prob- 
ably of  a  sufficient  number  of  sensory  cells  and  their  connecting  fila- 
ments, and  the  result  is  the  absence  of  mind.  The  general  conspicu- 
ous mental  weakness  of  an  idiot  is  the  lost  power  of  attention,  and  this 
accounts  for  most  of  the  pecuharities.  Xothing  impresses  him ;  percep- 
tion is  dulled,  concepts  are  weak,  and  emotions  are  not,  therefore,  legiti- 
mately aroused.  The  basis  of  mental  expression  is  the  bodily  or  instinc- 
tive feeling :  the  senses  of  hunger,  pain,  satiety,  comfort,  and  the  like^ 
influence  the  conduct,  and  liis  outward  manifestations  are  of  a  feeble 
nature  and  bear  a  close  connection  \nth  the  condition  of  the  ego.  The- 
expressed  feehng  is  unbalanced,  inhannonious,  and  is  often  evoked  by 
unexpected  or  ordinarily  ineffective  stimuli. 

The  speech  of  idiotic  children  has  alwa\^s  been  considered  an  inter- 
esting index  of  the  mental  failui'e.  Its  connection  with  the  disorderly 
complexity  of  organized  ideas,  and  the  manifestations  of  its  forms  of 
impairment,  perhaps  point  as  fully  as  any  other  sjTnptom  to  the  degen- 
eracy. The  defects  of  speech  vary  fi-om  absolute  mutism  to  a  state  of 
apparent,  though  feeble,  development,  where  perhaps  a  free  flow  of  words 
exists,  without  systematized  mental  creation  or  reg-ulation.  Many  vaga- 
ries are  found.  Sometunes  the  vocabulary  is  very  limited,  being  con- 
fined to  a  dozen  or  more  words  which  the  child  invariably  uses  for  the 
expression  oX  its  simple  wishes.  Hun  reported  a  case  of  this  kind,  and 
Clouston  another.  In  the  case  of  the  latter,  ten  words  served  to  des- 
ignate her  nui'se,  her  own  name,  those  of  various  animals  and  objects, 
as  well  as  to  convey  infonnation  as  to  her  needs.  Such  examiDles  are 
common  enough,  and  the  simple  words  are  curious,  and  frequently  have 
no  phonetic  connection  "v\ith  any  particular  object.  The  range  is  rarely 
extended,  though  occasionally  skillful  teaching  may  result  in  the  use  of 
new  and  api:)licable  exx^ressions.  The  speech-defect  is  sometimes  a  gen- 
uine aphasia,  and  is  associated  with  hemiplegia  and  epilepsy.  Other 
children  suljstitute  consonants,  using  T  for  K,  D  for  Gr,  D  for  Z,  etc. 
Echolalia,  sfammerinf/,  screamirifj,  the  utterance  of  rhythmical  and  monoto- 
nous sounds,  the  mimicry  of  the  noises  and  cries  of  animals,  are  all  morbid 
expressions. 

There  are  many  beautiful  childi-en  who  come  into  the  world  "oith  an 
utter  arrest  of  cerebral  development,  whose  beautiful  and  expressive 
faces  are  strangely  at  variance  with  the  paucity  of  mind.  Clouston, 
in  detaihug  a  case  where  there  was  an  hereditary  arrest  of  development 
of  the  mental  cortex  alone,  the  trophic,  motor,  and  sensory  centers  acting- 


ix.'ijyiTy  jx  it:s  medico-legal  leaiuxgs.  85 

normally,  while  there  was  no  emotion,  reasoning  power,  no  power  of 
attention  or  speeeh,  yet  "an  exeeptionally  sweet  faee,  fine,  expressive 
eyes,  wonderfully  good  walking,  and  a  well-formed  body,''  says :  "  The 
face  and  eye  of  such  an  idiot  tell  lies  when  they  thus  express  mind." 

The  sexual  organs  of  these  sulgects  are  sometimes  the  seat  of  mal- 
formations, and  mon()r(;liidism,  hermaphrodism,  and  atypical  errors  are 
disclosed  upon  inspection.  Their  sexual  appetite  is  perverted,  and  when 
any  desire  exists,  which  is  not  often  the  case,  the  adult  idiot  is  apt  to 
commit  violent  assaults  upon  women  and  children.  Although  copulation 
is  possible,  fertilization  does  not,  I  believe,  occur,  although  it  is  so  claimed 
by  some. 

The  idiot,  strange  to  say,  is  usually  susceptible  to  more  direct  and 
prompt  development  from  training  than  the  imljecile,  for  in  the  former 
there  is  often  no  actual  destruction  of  nervous  matter,  but  rather  a  dor- 
mant condition  that  can  be  much  improved  by  education — by  an  approach 
from  without,  that  is  to  say,  through  an  appeal  to  the  senses  primai'ily, 
and  a  removal,  if  possible,  of  the  inhibition  of  speech.  Teaching  should 
be  directed  to  symbol  formation  and  association. 

Cretinism  is  a  form  of  idiocy  attended  by  a  degeneration  of  the  thy- 
roid glands,  owing  its  origin  to  endemic  influences.  It  is  common  in 
southern  Eiu'ope,  especially  in  the  Pyrenees,  and  seems  to  be  rather  a 
disease  of  high  altitudes  than  elsewhere. 

The  physical  and  mental  peculiarities  of  cretins  consist  in  a  dwarfing 
of  stature  ;  imj^erfect  development  of  the  base  of  the  skull ;  a  puffiness 
and  swelling  of  the  face,  which  is  so  marked  in  myxcedema,  for,  in  fact, 
this  disease  belongs  to  the  same  group.  The  fingers  are  clubbed,  and 
the  tij^s  spatulous ;  the  skin  is  of  a  dirty,  waxy  color ;  the  surface  temper- 
ature is  lowered ;  the  voice  is  high-pitched,  raucous,  or  mufiled ;  the 
hearing  is  defective ;  the  mind  is  dull,  and  there  is  not  so  much  motor 
activity  as  in  ordinary  idiocy. 


II.    BIBECILITY  AND  lONDREJ)   DEGENERATIVE   STATES. 

Mental  weaknesses  beginning  during  the  fii'st  years  of  life  are  apt  to 
be  unnoticed  and  neglected,  and  it  is  not  until  the  third  or  fourth  year 
that  the  parents  realize  that  the  real  backwardness  of  the  child  is  due 
to  some  defect  in  organization.  It  perhaps  does  not  speak  or  walk  as 
soon  as  do  others  of  the  same  family,  and  possibly  has  a  spastic  gait,  or 
does  not  hold  up  its  head,  but  drools.  This  state  may  develop  after  an 
attack  of  convulsions,  a  febrile  disease,  or  "  brain-fever,"  or  is  associated 
with  epilepsy.  In  other  cases  there  is  no  such  condition  to  explain  its 
origin,  and,  in  fact,  the  mental  weakness  itself  may  not  consist  in  any- 
thing more  serious  than  a  '^  qneeiiiess  "  and  perversity,  which  causes  the 
subject  to  be  looked  upon  as  an  unusually  bad  or  an  unusually  clever 
child,  or  gains  for  it  frequent  and  useless  punishment,  or  adulation  or 
injudicious  praise  when  it  has  performed  sonu^  difficult  feat  of  mathe- 
matics or  menu^rized  some  very  long  verse  or  piece  of  prose.  To  this 
class  belong  the  nnisical  and  matheimatical  jii'odigies.  These  children 
are  usually  correspondingly  duU  in  other  things,  or  grow  up  to  be  stupid 
men  and  women.  The  moral  perversion  which  belongs  to  this  kind  of 
weakness  is  iiTegular  in  some  ways,  entirely  beyond  control,  and  is  fre- 


86  ^  SYSTEM  OF  LEGAL  MEDICINE. 

quently  ineradicable.  The  boy  commits  a  cruel  act  of  some  sort,  tortur- 
ing dumb  auimals  or  even  bis  own  kind;  again,  as  in  the  Pomeroy 
Case,  be  actually  commits  wanton  niui'der.  Lying,  steabng,  indecency, 
and  pui'poseless,  impulsive  acts  are  common.  There  is  afterward  little 
remorse ;  the  child  knowing  the  abstract  nature  of  its  offense,  often  talk- 
ing about  it,  but  feehng  no  shame.  Occasion allj^  the  subject  is  troubled 
by  doubts  and  fears  that  constitute  actual  introspective  insanity,  and 
acts  under  the  influence  of  imperative  eoncej^ts ;  but  this  is  not  common. 
The  mental  after-bfe  may  be  a  continuation  of  that  of  childhood,  and 
if  the  grade  of  degeneration  be  such  as  to  jDcrmit  an  actual  attempt  at 
progress  and  a  battle  with  the  world,  it  will  soon  be  found  how  improp- 
erly equipped  is  the  luckless  individual.  His  school  life  is  a  succession 
of  defeats  and  failures ;  his  business  career  is  fitful  and  unsuccessful,  and 
he  soon  di'ops  out  of  the  pushing  crowd.  His  disordered  moral  nature 
gets  him  into  trouble,  while  delinquencies,  expressed  in  the  direction  of 
theft  or  petty  crimes,  lead  him  fii'st  to  the  reformatory  and  afterward  to 
prison.  There  is  a  very  large  number  of  jDeople  in  the  community  who 
mingle  freely  with  their  fellows,  and  whose  real  condition  is  not  recog- 
nized. They  are  one-sided,  imitative,  and  perform  limited  intellectual 
work  where  little  inventive  skiU  is  required.  In  some  ways  such  peojDle 
are  decidedly  smart,  and  often  indulge  in  feats  of  memorizing  and  tours  de 
force  which  impress  then-  friends.  Thej''  are,  however,  without  sufficient 
reasoning  power,  and  their  judgment  is  bad.  One  of  them  may  be  a 
harmless  person  in  every  way,  the  butt  of  the  town,  the  village  wit,  or  he 
may  be  an  exceedingly  troublesome  member  of  society,  with  criminal 
instincts ;  in  fact,  a  very  large  number  of  instinctive  criminals  are  but 
imbeciles. 

So  far  as  the  physical  make-up  is  concerned,  we  find  peculiarities  of 
head  configiu*ation — what  is  known  as  "  developmental  ugliness  " — stra- 
bismus, defects  in  the  shape  of  the  ears  or  teeth,  eccentricity  of  dress,  and 
tricks  of  manner  and  speech.  The  term  coined  by  Guiteau  is  most  often 
ai)plicable  to  these  people,  for  they  are  often  cranks  in  action  and  ap- 
pearance. An  advanced  grade  of  mental  degeneration  is  manifested  in 
disorders  that  run  aU  the  way  from  "crankiness"  or  insane  eccentricity 
to  actual 

in.    M0X0:\L4XIA   OR   PARANOIA. 

The  use  of  the  word  "  monomania "  by  various  authors  has  led  to 
much  confusion.  It  has  been  apphed  to  forms  of  melancholia  and  mania, 
to  inteUectnal  insanity  (Hammond),  and  b}^  others  to  a  number  of  widely 
differing  psychoses,  ^y  some  it  has  been  considered  synonymous  with 
'' partial  insanity,"  that  convenient  legal  excuse  for  criminals  whose 
alleged  irresponsibility  is  connected  with  mental  integi'ity  in  all  other 
dii-ections  save  one.  From  the  fact  of  its  being  an  expression  of  initial 
degeneration  it  has  received  the  name  "primarj^  delusional  insanity." 
(Folsom.) 

Monomania  or  paranoia  is  an  insanity  in  which  the  mental  aberration 
consists  in  the  existence  of  limited  delusions  that  are  either  of  a  grand- 
ifjse  or  depressed  or  persecutory  nature.  The  genei-al  mental  health  of 
the  subject  is  not  always  bad ;  in  fact,  sometimes  the  pai'anoiac,  except 
for  his  OAvn  dominantly  expressed  delusion,  may  conduct  himself  with 


J.X^JXJTY  IX  ITS  MEDICO-LKCAL    liEAllIXaS. 


87 


<!(jiisider;il)le  propriety,  displaying  a  great  deal  of  intelligence.  Again, 
his  ijrominent  delnsion  is  a  central  one,  aljont  \vlii(*h  may  be  gronped 
others  of  a  dependent  kind,  with  a  growing  mental  dissolution  which  is 
finally  clear  to  all.  A  case  of  this  kind  lias  been  referred  to  wlien  describ- 
ing religious  delusions.  Ilallu«'inati<»ns  moi-e  rarely  occur,  and  wlum  they 
<lo  are  limited  like  the  delusions,  and  there  is  no  in(;ohcrence  ;  like  reason- 
ing insanity,  the  patient  reaches  concdusions  from  false  premises.  The 
emotions  correspond  with  the  delusions,  and  are  relatively  painful  or 
happy.     Paranoias  may  be  divided  into  several  varieties. 

The  iwrsccntofi)  form,  which  is  the  most  common,  where  the  individ- 
ual entertains  delusions  of  suspicion  and  persecution,  believing  himself 
to  be  the  obje(;t  of  attack  or  of  a  conspiracy,  that  he  is  deprived  of  his 
rights,  that  he  is  misunderstood  and  ndsjudged.  Possibl}^  his  delu- 
sion may  be  succeeded  by  others — of  power — he  Ijelieving  himself  to  be 
the  inventor  of  some  important  and  useful  piece  of  machinery  or  pro- 
■cess,  of  which  later  on  he  says  he  has  been  or  is  to  be  robbed  of.  Some- 
times he  is  the  great  general,  reformer,  or  manager,  and  if  he  really  has 
had  any  office  or  calling  which  he  has  improperly  filled,  he  refers  his  want 
of  success  to  his  imaginary  enemies,  who  have  plotted  his  ruin.  Persons 
who  sit  opposite  to  him  in  the  cars  are  enemies  and  detectives.  At  some 
time  or  other  he  misapplies  quotations,  both  bil)lical  and  otherwise,  and 
invests  himself  with  new  imaginary  power.  His  delusions  become  un- 
systematized eventually,  and  are  accompanied  by  auditory  hallucinations. 
He  "lias  a  mission  to  per- 
form," and  occasionally  mur- 
ders some  one  to  further  it, 
usually  a  president  or  sover- 
eign or  pulilic  functioiuiry. 

The  refotDKifori/  paranoi- 
<ie  would  regulate  society  ac- 
cording to  his  own  methods 
or  system.  If  he  occasion- 
ally has  sufficient  influence 
he  gets  himself  appointed  or 
•elected  as  president  of  some 
society  with  a  more  or  less 
noble  aim,  makes  and  en- 
forces persecutory  or  non- 
sensical regulations,  and  his 
zeal  is  insane  in  its  exhibi- 
tion, and  draws  f  oi-th  censm-e 
and  newspaper  abuse,  no 
matter  how  sincere  he  may 
"be.  He  may  be  and  usually 
is  eccentric  in  dress,  and 
should  his  delusions  be  of  a 
grandiose  character,  deco- 
rates himself  with  medals  and  decorations.  In  an  extreme  form,  which 
has  received  the  name  niPf/aJoiiKOiif  fronrthe  French,  we  find  the  most  ex- 
travagant delusions  of  power  expressed.  There  is  usually  an  expansive  hien 
etre  and  benevolence  displayed  which  lead  the  individual  to  promise  the 

*  From  the  author's  Types  o/  In»an%t]jy  with  kind  permission  of  WilUam  Wood  &  Co. 


88  -i   SYSTEM   OF  LEGAL  MEDICINE. 

favors  that  only  a  king  could  confer.  He  is  invulnerable  and  impervious^ 
to  the  bullets  that  may  be  fii-ed  at  him ;  he  makes  his  attendant  a  general 
or  duke,  or  promises  his  visitor  a  million  or  two  as  a  pledge  of  his  good- 
fellowship.  He,  too,  is  decorated  with  shining  bits  of  metal,  buttons,  feath- 
ers, boot-heels,  and  a  thousand  and  one  glittering  gewgaws  he  has  picked 
uj)  or  begged.  (Fig.  22.)  Should  he  be  interviewed  in  an  asylum  ward  he- 
calls  attention  to  the  fact  that  all  those  about  him  are  insane,  and  he  alone 
is  in  possession  of  his  faculties,  but  does  not  seem  to  wish  to  escape. 

In  one  case  of  which  I  know  the  patient  called  attention  to  his  inven- 
tion of  "painless  death."  The  secret  was  "too  dangerous  to  geueralljr 
communicate,"  but  he  gave  me  the  formula,  which  I  produce.  The  pain- 
less death  was  to  be  produced  by  a  blow  with  the  fist,  not  in  a  vital  spot,.. 
but  anj^where.  It  was  suggested  for  the  execution  of  criminals,  but  the 
secret  "  should  not  be  imparted  to  persons  likely  to  use  it  for  revenge." 

About  Painless  Death  formula,  joxi  multiply  the  weight  of  the  man  who  strikes  bjr 
the  length  of  his  extended  arm  and  by  the  length  of  the  advance  of  his  foot  as  he- 
throws  himself  forward;  the  total  divide  by  2000  or  2240  lbs.,  giving  the  energy  in 
foot-pounds — generally  1^  to  1^  tons.  This  should  be  verified  by  actual  test  on  scale- 
register. 

Upon  reminding  him  that  blows  of  this  kind  rarely  resulted  in  any 
serious  injury  though  inflicted  every  day,  he  replied  that  "  some  of  the- 
conditions  were  absent." 

A  class  of  paranoiacs  infest  the  courts  of  law,  bringing  suits  for  all 
sorts  of  imaginary  injui'ies,  and  badgering  and  bothering  judges  and 
juries.  This  paranoia  lifigiosa,  or  quendent  insanity,  is  common,  and  its 
victims  are  usually  j)ublic  nuisances  who  are  always  getting  into  trouble. 
An  e^ddence  of  this  form  of  disease  is  j^resented  in  the  shape  of  the  in- 
dorsement of  a  brief  executed  by  a  j)aranoiac  who  imagined  himself  jDerse- 
cuted  and  depriA^ed  of  his  rights  as  a  lawj^er.  The  bombastic  phraseology 
is  highly  characteristic.  This  paper  consists  of  a  legal  form,  which  is  ad- 
di'essed  to  "the  United  States  and  whole  world,  as  before  the  Court  and 
Counsel,  yet  with  this  legal  estoppel :  etjusticia  ad  infinitum"  and  within : 

It  appearing  to  my  satisfaction  that  Mr.  G-.  K.  is  the  Chief  of  the  Bar,  and  i& 
clothed  with  all  rights,  privileges,  honor,  and  justice. 

Ordered  that  the  Hon.  J.  S.,  Justice  of  said  court,  is  in  full  sympathy  ■ndth  the  said. 
K.,  and  that  he  has  sworn  that  his  obligation  is  in  all  respects  toward  the  said  K.,  to- 
do  anything  to  his  aid  and  advantage  for  the  modification  of  61  Barb.  p.  573,  even  unto> 
death,  as  our  inviolable  rights  and  only  legal  settled  citizen  title,  as  registered  in  rem.. 

J.  S.,  Justice. 

On  the  back  of  the  paper  appears  the  following : 

TAKE    NOTICE. 

To  all  to  whom  it  may  Concern  : 

That  the  Avithin  is  a  copy  of  an  order  this  day  filed  in  the  Clerk's  Oifiee  of  the  5th; 
Judicial  District  Court,  as  this  our  home  and  international  legally  settled  jusgentium 
measured  inviolable  privileged  benefit,  for  the  other  nations  and  people  of  the  other- 
sections  of  the  globe,  for  all  religious  denominations  and  sects,  and  the  various  politi- 
cal parties  and  fractions  and  representations.  You  will  please  restrain  and  hold  over,, 
and  do  the  same  bv  signing  same. 

N.  Y.,  May  9th',  1883.  JOHN  SMITH. 

These  and  many  others  are  familiar  to  the  public  through  their  ex- 
traordinary behavior,  accounts  of  which  have  found  their  way  into  the 
newspapers;  but  the  real  condition,  unless  it  is  very  pronounced,  i& 
rarely  appreciated. 


IXSAXITY  IX  ITS  MEDICO-LEGAL  BEARINGS.  89 

The  development  of  i)aranoiii  is  slow,  and,  as  it  has  a  congenital,  neu- 
rotic basis,  we  find  a  previons  life  characterized  by  some  of  the  early 
peculiarities  of  conduct  alluded  to  in  describinj^  imljecilit}'.  The  down- 
ward progress  of  the  disease  is  slow  but  sure,  the  patient  entertaining  a 
limited  number  of  delusicjns  for  many  years  before  lapsing  into  dementia. 
The  subjects  are  tolerated  menil)ers  of  society,  and  not  unrarely  do  much, 
good  in  directions  whei-e  their  diseased  intelleet  does  not  interfere.  Para- 
noia is  essentially  a  ehronic  disease,  though  lately  a  form  has  been  de- 
scribed which  is  said  to  be  acute.  I  am,  however,  disposed  to  believe  that 
the  very  nuitter  of  time  must  exist  to  determine  the  natiu'e  of  the  disease, 
for  short-lived,  single  delusions,  even  with  insane  predisposition,  may  be 
found  under  other  circumstances,  and  may  symptomatize  many  ordinaiy 
acute  insanities.  It  therefore  does  not  do  to  speak  of  an  acute  paranoia. 
Suicide  is  not  common,  and  homicide  is  resorted  to  only  when  delusions, 
of  persecution  or  conspiracy  exist,  or  when  tlie  person  is  being  restrained 
or  his  acts  controlled. 

A  form  known  as  Sensorielle  VerriicJdheit  exists  when  the  limited  de- 
lusion springs  from  some  alteration  of  sensation  and  relates  to  the  body; 
by  some  authors  it  has  been  called  hypochondriacal  paranoia. 

The  following  statement  is  that  of  an  ignorant  paranoiac  of  this  kind 
whose  disease  had  had  a  hypochondriacal  beginning,  and  developed  so 
that  uns^'stematized  delusions  of  persecution  and  conspiracy  followed  a 
period  characterized  b}^  the  existence  of  limited  hallucinations  and  cor- 
poreal delusions  relating  to  liis  own  internal  organs.  He  came  from  in- 
sane stock.  The  "Arenoughts"  (Argonauts)  were  throughout  respon- 
sible for  his  persecution. 

THE  ARENOUGHTS. 

March  lltli  1886 

My  Bowels  Moved  3  times  Before  night  parties  or  areiioiights,  qiiite.  quiat  I  com- 
menced Tacking  the  Medeson  No  1862  .   .   .  3  11  86  Prescription  from  G  R  C Have 

taken  the  first  dost  in  the  evening  12th  1886  The  parties  threaton  me  with  Blindness ; 

I  have  faith  to  Beleive  G D  L and  J F  F ;   I  Have  ben  threatond 

Several  times  before  and  a  Blur  Before  my  eyes  Bowels  Moved  twice  today  now  8 
Oclock  at  night  I  Beleive  the  parties  Have  power  of  My  Mind  and  Brain  and  they 
have  acnowladged  thy  have  My  papers  and  a  Recept  Book  and  a  pair  of  Shomakers 
Pincers  and  Recepts  of  My  Trade  whiteh  I  Hope  and  Pray  May  Be  Restoared  back  to 
Me  And  they  further  Have  acnowladged  they  have  ben  Rested  by  Myfolks  and  that  they 
are  going  to  Noculate  Me  the  same  This  said  tonight  the  Twelfth  Whiteh  I  think  the 
Parties  noculated  My  famely  and  went  up  to  Be  free  from  the  law  and  Me  By  the  fam- 
ely  being  put  from  Me  by  their  commandments ;    also  they  have  claimed  they  are 

going  to  Mation  Me  for  their  Brother  J F and  all  My  acts  of  Mine  and  J 

F is  not  to  Be  found  He  J F agi'eed  to  Make  Me  clear  of  Debt  if  I  would 

Stick  to  him  until  He  got  His  Pentiou  whiteh  I  Did  and  the  contract  was  never 
done 

My  Head  and  Chest  Bounced  like  ones  Hart  after  rimning  fast  a  long  distance  at 
Night  the  Parties  notime  letting  np  entirely 

16  they  Sometimes  punch  ile  at  the  root  of  My  Tongue  and  other  times  at  My  toes 
and  other  times  at  My  Heals.  The  parties  claim  tliat  thare  is  nothing  the  Matter  with 
them  and  Say  that  I  was  spirited  So  if  they  are  blowed  off  they  will  come  back  or  send 
Some  won  else  as  thy  Now  the  Spirit  in  Me  and  can  throw  on  me  at  any  time 

Mr  A What  will  be  the  expence  to  Have  you  and  Me  go  to  N  Y  city  to  a  ^lition. 

Horsepittle  or  any  Horsepittle  and  Have  this  Tested* 

Pleas  Return  this 
My  Medeson  8  quorters  used  up 

*  His  urine. 


90  A   SYSTEM  OF  LEGAL  MEDICLXE. 

March  20  1886 

The  arenoughts  Say  this  Morning  that  They  wont  come  S D on  Me  for  I 

hant  the  Money  to  btildoze  him  backwards  and  forwards 

As  1  am  thinking  about  a  bill  Dr  L ast  Me  to  pay  yesterday ;  While  I  was  talk- 
ing with  L the  fiarties  were  operating  on  my  Niu-vs  so  i  trembled  allover  astho  I 

was  as  cold  as  eoiild  be  without  freezing;   and  they  continue  to  operate  on  my  ears 

daly;  for  thatmatter  all  over  Me  fi-om  place  to  place ;  A  L Bill  $10.50  cts;  sui-- 

Tises  10th  of  Feb  copy  March  18 

They  say  Im  capable  of  Putting  Him  down  And  putting  Him  up  in  one  Minute 
when  they  were  Making  Me  shack  astho  Im  Half  froze  Ive  thought  of  bui'ning  Sulf or 
in  My  Durtcellar  and  get  in  the  back  side  will  it  Harm  me  if  I  sit  in  the  bottom  at  the 
backside  at  the  bottom    My  bowels   scarcely  any  better  Moving  3  or  4  times  a  day 

20  while  sitting  in  Sloats  shop  The  parties  up  in  The  air  said ;  He  Avont  be  able  to 
plead  His  own  cause  so  Splay  And  My  Head  Had  a  dull  Heavy  Ach  and  then  spoke  as 
thoug  speaking  to  one  in  company  with  him  Oh  will  He  go  to  Adamses ;  I  feeling  half 
asleep 

21  They  said  That  my  place  would  be  sold  to  findout  whare  My  Money  was  and  if 
I  dident  By  it ;  It  would  be  given  back  to  My  wife  and  if  I  dideut  Live  with  Hui"  They 
would  Murder  Me  and  Saying  that  Mis  Wimon  was  diseased  by  them  and  They  were 
going  to  Mation  or  Mition  them  and  My  Money  Had  to  pay  them  for  it  &  tonite  They 
were  oijeratiiig  on  my  body  So  I  could  hardly  Breath  Near  my  Xabol  &  felt  as  though 
it  was  Strained  out ;  near  the  same  as  ones  finger  in  a  Adee  and  turning  Black  with 
the  preshure ;  Xow  as  I  am  riting  they  say  is  he  arny  worse  of  than  he  was  &  the 
other  says  He  would  if  we  wasent  Afrade  of  Adams ; 

22  Tonite  The  parties  commenced  pumping  on  my  Head  up  and  down  the  Hollar 
of  My  Neck  About  whare  the  spine  is  and  so  down  about  as  far  as  the  bottom  of  my 
Sholder  Blades.  I  think  one  could  have  seen  My  Head  Move  this  done  after  I  got  in  bed ; 
Soon  as  I  got  up  to  rite  this  they  let  up  after  I  again  got  in  bed  they  commenced  to 
operate  again  I  was  thinking  about  going  up  to  The  Justice  of  the  Piece  and  they  said 
they  would  put  me  so  low  I  eouldent  pleed  my  own  case  I  not  nowing  whitch  to  see 
first  you  or  the  oficer ;  They  said  By  God  they  did  not  now  whitch  way  to  do  as  they 
did  not  now  whitch  way  I  would  go  ; 

23  My  Bowels  so  loos  it  rujis  from  me  like  water  I  not  Being  able  to  now  some- 
times before  its  dun ; 


IV.   ADOLESCENT   INSANITY. 

One  of  the  critical  points  of  life,  when  the  mental  equilibrium  is  most 
sensitive  to  disturbing  agencies,  is  that  of  pubescence.  It  is  at  this  time 
that  the  second  period  of  brain  development  really  begins.  "  Looking  to 
the  gradual  development  of  mind  up  to  pubert}',  and  the  enormous  and 
rather  sudden  leap  that  is  then  taken  to"svard  the  higher  mental  life  of 
the  adult,  we  must  assiune  an  ahnost  completed  apparatus  Ijdng  ready 
to  be  brought  into  use,  just  as  the  centers  of  respiration  are  read}^  for 
theu'  functions  at  birth ;  and  considering  that  the  very  highest  mental 
and  moral  qualities  of  all,  wiih  the  subtle  differentiation  between  the 
male  and  female  mental  tj'pes,  are  only  fully  seen  between  eighteen  and 
twenty-five  in  the  average  human  being,  we  must  look  still  to  the  appa- 
ratus throitgh  which  all  this  is  JDrought  about  in  the  brain  cortex." 
(Clouston.) 

In  cliildren  possessing  the  insane  diathesis  a  very  serious  and  often 
incurable  psychosis  dcA'elops,  and  is  apt  to  afterward  end  in  dementia. 
In  those  with  unstable  brains  various  foi'ms  of  mental  disease  may  appear 
much  earlier  than  at  puberty,  and  insanity  in  children  of  even  five  or  six 
has  been  observed.  The  variety  above  alluded  to,  kno^^^l  as  adolescent 
insanity,  is,  however,  quite  peculiar.  It  is  symptomatized  by  excitement, 
irritabihty,  and  impulsive  acts,  though  melancholia  exists  in  a  fair  jjer- 
centage  of  cases.     The  moral  sense  is  blunted  and  sexual  perversion  is 


IXSAXITY  JX  ITS   MEDIL'O-LECAL    liEARIXGS.  91 

common.  The  male  sul)ject  is  insanely  vain  and  conceited,  bomhastic^ 
and  ji'enerally  m(>i'l)id.  Some  writers  have  desciibed  the  disorder  as  mas- 
tnrbatic  insanity,  beeanse  the  hai)it  of  onanism  is  snpposed  to  precede 
and  canse  the  insanity.  I  do  not  think  this  term  is  proper,  or  the  etio- 
logical theory  of  masturbation  tenable,  for  the  sexual  vice  is  rather  more 
apt  to  be  the  cause  than  the  result.  Various  emotional  disturbances  are 
common  in  both  sexes,  and  there  is  a  certain  periodicity  which  reseml^les 
foUe  circuldire.  A  large  numl)er  of  cases  recover  wholly  or  partially, 
though  about  thirty  percentum  lai)se  into  a  profound  dementia  charac- 
terized by  good  physical  health  (primary  dementia  of  youth.)  The  affec- 
tion must  always  be  considered  as  a  developmental  psychosis. 


V.   PERIODICAL  INSANITY, 

{Folie  Circulah'e;  Alternating  Insanity.) 

The  clinical  features  of  this  form  are  reem-ring  attacks  of  mania  and 
melancholia,  ordinarily  in  subjects  with  hereditary  tendencies,  though 
an  acquired  form  is  mentioned  where  states  of  elation  or  depression  may 
be  repeated.  The  attacks  are  separated  by  intervals  of  apparent  lucidity, 
but  it  is  a  question  whether  the  intervening  condition  is  ever  one  of  ab- 
solute integrity.  The  exacerbations  seem  to  be  due  to  internal  causes, 
and  are  evidently  the  result  of  cumulative  physical  depression  and  mental 
disorder.  The  actual  attacks  of  insanity  tend  to  become  more  and  more 
frequent,  and  eventually  run  together,  the  resulting  condition  being  a 
terminal  chronic  psychosis,  though  this  is  by  no  means  an  inevitable 
consequence.  Sometimes  the  attacks  are  always  of  melancholia  or  mania, 
or  they  alternate  irregularly.  The  former  are  apt  to  be  simple  and  not 
hallucinatory,  and  the  delusions  are  often  in  regard  to  personal  unfitness 
or  are  of  a  clearly  religious  nature.  The  delusion  does  not  last  very  long, 
but  rapidly  disappears.  The*  remembrance  of  the  attack  is  at  first  clear 
in  the  interval,  but  after  subsequent  attacks  the  mental  condition  and 
power  of  attention  is  confused,  as  it  is  in  old  epilepsy,  and  the  recol- 
lection dim.  When  the  character  of  the  disease  is  excitement,  such 
excitement  is  apt  to  be  of  sudden  occurrence  and  subsidence.  There  is 
great  irritability,  shai'pness  of  memory,  loquaciousness,  self-aggrandize- 
ment, and  morbid  self-confidence ;  incoherence  and  active  hallucinations 
in  a  small  number  of  cases.  The  feature  of  both  mania  and  melancholia 
of  this  kind  is  the  short  duration  of  the  separated  attacks,  which  usually 
last  but  a  few  weeks.  Seasonable  factors  seem  to  influence  the  changes 
that  are  observed,  but  it  is  difficult  to  say  how. 


VI,   REASONING  INSANITY. 

{Reasoning  Monomania;  Monomania  sine  Delirio.) 

Many  patients  possess  a  remarkable  abihty  to  con^dnce  themselves, 
as  well  as  others,  as  to  the  apparent  consistency  of  more  or  less  insane 
acts  which  they  perform.     Tliis  form  of  insanity,  therefore,  is  one  that 


92  ^   SYSTEM  OF  LEGAL  MEDICINE. 

is  apt  to  be  the  basis  of  litigation,  because  of  the  apparent  intellectual 
\dgor  of  the  subject.  Its  elements  are  originally  false  premises,  from 
which  he  oftentimes  reasons  most  logically,  arriving  at  a  conclusion 
which  may  amount  to  a  powerful  imperative  concept.  In  most  ways  his 
ordinary  mental  conduct  may  be  all  that  it  should  be,  but  the  false  in- 
sane idea  exists,  and  is  defended  and  justified  with  great  vigor.  Not 
unrarel}"  the  patient  recognizes  his  weakness  at  some  time  or  other,  and 
undergoes  great  agony  of  mind.  As  the  result  of  this  dominating  Mud 
of  thought  he  makes  purchases  he  can  ill  afford,  or  buys  useless  things, 
or  is  dangerous  to  society.  His  acts  are  often  preposterous,  but  after 
their  commission  he  is  filled  mth  remorse  and  makes  a  manful  effort  to 
avoid  the  mandates  of  his  specious  conclusions.  This  disorder  closely 
resembles  the  other  affection  which  is  expressed  in  the  origination  of 
morbid  imperative  concepts,  and  may  be  said  to  be  an  exaggerated  form 
of  that  psychosis,  as  in  it  there  is  often  a  neurotic  element  or  a  history 
of  alcoholism  in  other  generations.  The  patients  are  usually  adults.  I 
have  lately  seen  several  children  who,  however,  have  developed  the  psy- 
chosis. 

A  few  months  ago  a  boy  of  foiu-teen  was  sent  to  me  who  presented  a 
form  of  this  disorder,  which  I  believe  to  be  unusual,  and  which  was  due 
to  improper  religious  training  in  a  subject  of  defective  organization. 
He  studied  hard  and  was  ambitious,  and,  as  a  consequence,  had  developed 
headaches  a  year  ago,  with  indigestion  and  general  ill  health.  Some 
months  ago  his  mother  noticed  that  he  washed  his  hands  more  fre- 
quently than  usual,  and  that  he  would  stand  a  long  time  before  the  basin 
in  an  apparently  abstracted  state ;  that  he  would  spit  iii  the  coal-scuttle 
repeatedly,  and  that  he  picked  up  pieces  of  straw  and  matches,  which 
were  always  tlu'own  into  the  coal-scuttle.  He  explained  his  actions  by 
saying  that  the  pieces  of  straw  resembled  crosses,  and  he  could  not  show 
disrespect  by  carelessly  stepping  upon  them.  His  habit  of  spitting,  he 
said,  Avas  due  to  the  fear  lest  the  saliva  in  his  mouth  should  interfere 
with  the  fidl  effect  of  the-  communion-wine,  and  this  was  carried  still 
further  b}-  spitting  in  his  handkerchief.  Of  late  he  occasionally  has  de- 
lusions that  his  food  is  poisoned,  but  he  denies  this  to  me.  When  he 
crosses  the  railroad  tracks  that  run  near  his  house  he  is  impelled  to  pick 
up  stones  that  lie  between  the  rails ;  if  he  does  not  do  so  he  is  filled  with 
fear  lest  there  may  be  a  railroad  accident.  He  has  all  the  distress  of 
mind  common  to  other  sufferers  from  this  form  of  trouble  if  he  neglects 
to  foUow  his  first  impulses,  and  often  returns  to  obey  the  dominant  con- 
cept. 

He  often  remains  for  a  long  time*  in  the  water-closet,  sometimes  for 
ten  or  fifteen  minutes,  and  when  his  mother  enters  to  find  the  reason  of 
his  seclusion,  she  discovers  that  he  has  littered  the  place  with  many  pieces 
of  discarded  water-closet  jjaper,  refraining  from  desecrating  by  use  anj^ 
piece  that  contains  ci'cases  that  may  bear  any  resemblance  to  the  com- 
mon symbol  of  Christianity,  he  examines  each  piece  carefully.  He 
sleeps  very  badty  and  has  nightmares,  and  grinds  his  teeth.  His  pockets, 
when  examined,  are  often  found  to  contain  vaiious  nails  and  sharp 
things  that  he  has  placed  there  after  picking  them  up  lest  they  might 
injure  some  one. 

When  I  talked  with  him  I  found  little  or  no  intellectual  disturbance, 
and  consider  that  his  objections  to  his  food  were  not  so  much  because  he 


IX.S.iXITY  IN  ITS  MEDICO-LEGAL   BEARINGS.  93 

thought  it  was  poisoned  as  IxT-auso  it  inig'lit  in  some  way  interfeve  with 
liis  rehgioiis  professions  and  duties;  but  from  Ijis  motli<!i"'s  aeeount  lie 
undoubtedly  at  other  times  has  well-marked  liallucinations  and  delu- 
;sions.  He  expressed  mueh  distress  in  regard  to  his  condition,  and  I 
think  to  some  extent  realized  its  hold  over  him.  Upon  interrogation  I 
found  that  whenever  he  walked  in  the  street  he  carefully  put  out  of  the 
way  or  picked  up  any  o))ject,  especially  pieces  of  straw,  wood,  or  paper, 
that  in  any  way  in  their  an-angement  l)()re  the  least  res(imblance  to  a 
•cross,  for  fear  that  he  might  commit  some  act  of  saci'ilege.  After  much 
questioning  it  turned  out  that  he  had  received  a  deep  mental  impression 
from  a  story  in  a  semi-religious  school  "reader,"  whicli  was  in  use  at  the 
lioman  Catliolic  school  which  he  attended ;  and  upon  examining  the  book 
I  found  a  highly  colored  romance  which  had  evidently  been  prepared  for 
.the  purpose  of  appealing  to  impressible  children  of  his  particular  faith. 


Vn.   EPILEPTIC  AND   HYSTERICAL  INSANITY. 

These  forms  are  characterized  by  the  primary  existence  of  epilepsy, 
«or  a  fundamental  hysterical  state  which  becomes  more  and  more  pro- 
nounced until  the  expressions  of  emotional  excitement  always  rise  to 
the  surface  and  give  the  mental  disorder  a  distinct  tinge.  In  the  former 
the  mental  aberration  is  of  irregular  development.  It  is  always  heredi- 
tary, and  may  follow  the  occurrence  of  frequent  attacks  of  i)etit  niaJ, 
when  the  type  is  that  of  mental  feebleness,  finally  possibly  amounting 
to  dementia.  In  other  varieties  there  may  he  attacks  of  excitement, 
which  take  the  place  of  epileptic  paroxysms,  during  which  iihe  patient 
-commits  acts  which  he  does  not  afterward  rememl)er.  This  form  of  dis- 
ease must  be  distinguished  from  the  epileptic  manifestations  of  general 
paresis,  of  embolism  or  coarse  disease  of  the  brain,  where  the  attacks  are 
generally  symptomatic.  Sometimes  the  insanity  is  expressed  in  melan- 
■cliolia,  with  delusions.  The  mental  disturbance  may  be  short-lived,  tak- 
ing the  place  of  or  following  a  fit.  There  is  great  irregularity  in  the 
•occurrence  of  the  isolated  attacks,  and,  in  fact,  in  regard  to  the  progress 
•of  the  disease.  It  rarely  affects  children,  except  as  a  symptomatic  ex- 
pression, but  often  develops  about  the  time  of  pul)erty. 

With  the  motor  automatism  which  we  often  find  the  patient  commits 
<;urious,  purposeless  acts  which  are  so  eccentric  as  to  leave  no  doubt  of 
mental  unsoundness.  One  of  my  patients  would  disrobe  wherever  she 
happened  to  be.  Others  unconsciously  pursue  the  accomplishment  of 
-acts  that  were  in  process  of  commission  before  the  seizure  or  lapse  of 
^consciousness,  of  which  they  have  no  recollection.  While  the  functional 
activity  of  the  higher  cortical  centers  is  suspended,  the  patient  may 
wander  sometimes  to  a  great  distance,  take  railroad  journeys,  and  travel 
with  other  people,  who  detect  nothing  unusual  in  his  conduct.  On  his 
return  he  is  often  oblivious  of  any  irregularity,  or  remembers  nothing  of 
where  he  has  been  or  what  he  has  done.  The  iinportance  of  such  a  state 
cannot  be  disregarded  as  an  element  of  legal  proceedings,  when  it  is 
-claimed  that  certain  acts  are  not  the  product  of  the  free  will  of  the  sul)- 
ject.  The  relation  of  epilepsy  to  criminal  responsil)ility  will  be  later 
considered,  l)ut  attention  is  here  directed  to  the  possibility  of  the  com- 
mission of  an  act  by  an  epileptic  with  a  masked  or  aborted  form  of  the 


94  A   SYSTEM  OF  LEGAL  MEDICLXE. 

disease,  which  would  jeopardize  his  ci\dl  rights.  Such  a  person  migiit 
very  readily  make  a  civil  contract  of  which  he  would  have  no  recoUection 
subsequently,  and  which  would  not  be  approved  by  him  in  his  normal 
state. 

The  h^'sterically  insane  are  subjects  of  the  neiu'otic  temperament,  and 
it  is  not  difficult  to  find  some  history  of  degeneration.  They  belong,  as  a 
rule,  to  families  other  members  of  which  are  alcoholics,  insane,  or  in- 
stinctive criminals.  The  elation,  vanity,  irritability,  and  general  emo- 
tional instability  of  these  patients  lead  to  exaggeration,  moral  blunting, 
and  consequent  improj)riety  of  conduct, which  is  also  expressed  in  alcoholic 
and  epileptic  insanity.  The  delusions  and  hallucinations  are  rarely  ad- 
hered to,  are  changeable,  and  are  not  always  real,  but  are  due  to  what 
may  be  called  a  willful  autoh^^Duotism  or  voluntary  indidgence  in  image- 
forming.  So  lively  and  absorbing  is  this  process  that  a  morbidly  active 
woman  may  pass  into  an  ecstatic  condition,  examples  of  which  are  com- 
mon enough  during  times  of  religious  revivals.  Such  patients  are  dis- 
posed to  mutilate  themselves  for  the  purpose  of  gaining  sympathy  and 
notoriety,  and  are  untruthfid,  sexually  debased,- and  prone  to  make  un- 
just charges  against  innocent  jjeople. 

Helen  Miller,  whose  case  is  reported  by  Dr.  Channing  {Am.  Journal 
of  Insanitij,  Januarj^,  1878,  p.  368),  came  under  my  observation  some 
years  ago.  She  had  coimnitted  thefts  from  doctors'  offices,  and  was 
arrested  and  sent  to  prison.  While  there  she  began  to  feign  insanity 
and  was  sent  to  the  Asylum  for  Insane  Criminals.  She  had  been  of 
hysterical  habits,  had  eaten  opium,  and  was  treated  by  one  of  the  physi- 
cians she  had  robbed  for  dysmenoi-rhoea.  Her  fii-st  exploit  in  the  asylum 
was  to  prick  her  gums,  and  the  blood  therefrom  was  mixed  with  urine 
and  crumbled  bread,  so  that  an  attack  of  hematemesis  was  suggested. 
She  had  several  attacks  of  hysterical  dysmenorrhoea,  was  irritable,  de- 
pressed, and  had  fits  of  temper.  Then  slie  began  a  system  of  self-muti- 
lation which  was  something-  extraordinary.  At  various  times  she  thrust 
pieces  of  glass,  sphnters,  and  other  things  into  various  parts  of  her 
bodyj  cut  herself  with  pieces  of  tin  and  a  broken  bottle.  Upon  one 
occasion  she  broke  her  chamber  over  her  head.  Dr.  Channing  removed 
no  less  than  ninety-foiir  pieces  of  glass,  thu-ty-fom-  splinters  of  wood, 
two  tacks,  four  shoe-nails,  one  pin,  and  one  needle,  at  various  times.  In 
this  case  the  woman's  pride  seemed  to  be  that  she  was  the  object  of  sur- 
gical interest  and  of  sjTnpathy.  I  saw  her  after  her  transfer  to  the 
BlackweU's  Island  Asylmn,  where  she  was  sent  after  her  second  arrest 
for  theft,  as  she  had  been  discharged  from  the  Auburn  Asylum  when  her 
first  sentence  had  expired.  She  was  hysterical,  but  I  found  no  impress- 
ing intellectual  derangement,  and  I  shoidd  not  consider  her  legally  in- 
sane, though  her  psychosis  was  in  some  respects  a  gi-ave  one. 

Cases  are  detailed  where  women  have  set  fii-e  to  buildings,  or  the 
clothing  of  children,  and  were  unable  to  give  any  motive  for  the  crime. 
There  is  another  class  of  cases  the  subjects  of  which  claim  that  they  have 
been  outraged  or  maltreated,  and  give  the  impression  that  self -inflicted 
wounds  were  made  by  their  assailants,  and  as  a  resiilt  innocent  persons 
are  occasionally  arrested.  In  such  cases  local  examination  wiU  rarely 
reveal  any  indication  of  violence,  but  in  cases  of  women  of  questionable 
purity  it  is  a  difficult  matter  to  swear  positively  from  any  examination 
that  their  stories  are  not  time. 


INSANITY  IN  ITS  MKDICO-LKGAL   nEAUINGS.  95 

Tho  papers  were  filled  some  years  a^o  with  the  reniarkahle  declara- 
tions of  a  young-  woman,  who  lived  in  an  interioi-  t<jwii  in  New  York, 
and  wiio  claimed  that  while  alone  in  the  house  she  was  surprised  by  the 
entrance  of  masked  robbers,  who  bound  and  g'agg(^d  her,  and  applied 
chloroform  upon  a  cloth  to  her  face,  and  after  assaidting-  her  brutally  she 
became  nnconscious.  The  st(n-y  was  so  palpably  frandident  that  it 
should  have  reccivinl  little  or  no  recognition  by  those  a)>ont  her;  but,  as 
in  other  cases  of  the  kind,  we  find  sympathetic  friends  and  a  sensation;d 
press  ever  ready  to  believe  in  aiid  give  publicity  to  tlie  hysterical  j)laint 
of  the  impostor.  In  this  case  the  ropes  that  bound  her  were  evidently 
applied  by  herself,  and  tlie  quantity  of  cldoroform  alleg-ed  to  have  been 
used,  a  small  bottle  having  been  found  (which  it  trans])ii-ed  she  had 
bought  herself),  made  her  story  appear  at  once  manifestly  absurd.  This 
case  is  unlike  the  last  in  the  superficial  character  of  the  disease. 

Hysterical  insanity  is  occasionally  epidemic,  and  may  appear  as  the 
result  of  imitation.  Folie  a  deux.,  which  is  generally  considered  a  more 
sei'ious  form  of  insanity,  is,  I  believe,  nearly  always  of  hysterical  origin. 
I  have  known  of  one  isolated  and  clear  instance  of  imitative  hysterical 
insanity  in  which  two  members  of  an  unfortunate  family  became  the 
subjects  of  a  condition  bordering  upon  hysterical  mania.  An  hysterical 
girl  was  taken  to  the  mountains  for  her  health,  but  no  benefit  was  de- 
rived from  the  change,  and  she  grew  more  violent  and  unreasonable. 
Her  mother,  and  a  sister  veiy  nearly  her  own  age,  were  her  companions 
and  constant  nurses.  Upon  their  return- journey  to  New  York  the  sister 
showed  an  unnatural  excitement,  which  developed  before  they  reached 
Troy  into  a  veritable  hysteiical  mania.  They  raved,  and  became  so  vio- 
lent that  the  hotel  proprietor  in  that  city  turned  them  out  of  his  house 
and  put  them  on  the  cars ;  but  in  Albany  they  again  rested,  and  their  sad 
condition  being  mistaken  for  drunkenness,  they  were  arrested,  but  Avere 
finally  released  and  again  began  their  joiumey  to  New  York,  the  mother 
being  now  in  a  partially  responsible  state,  as  she  had  been  half  crazed 
by  the  excitement  and  disgrace.  They  finally  reached  New  York  and 
went  to  a  hotel,  where  they  stayed  for  a  night  only,  as  one  of  the  sisters 
tried  to  force  hei"  way  through  the  fanlight  over  the  door  of  her  room, 
and  so  alarmed  the  guests  that  the  police  were  called  in  and  they  were 
arrested  and  taken  to  headquarters.  They  were  removed  by  some 
friends,  and  I  subsequently  examined  them.  The  mental  disorder  in 
this  case  was  sexual,  and  it  became  so  much  worse  that  the  patients  were 
finally  sent  to  an  asylum. 

In  such  cases  as  this  the  question  of  responsil)ility  is  an  interesting 
one,  and  it  is  evident  that  the  final  action  of  the  Albany  judge,  who  first 
thought  the  patients  intoxicated  and  afterward  sent  them  out  of  to\Am, 
went  to  show  that  the  behavior  of  the  gii"ls  was  not  looked  upon  as 
criminal. 

VIII.   ALCOHOLIC  INSANITY, 

Or,  more  properly,  the  insanity  of  alcohoUstn,  is  an  acute  or  chronic 
condition  pr-oduced  l>y  the  toxic  use  of  alcohol  in  its  various  forms. 
Wliere  the  alcohol  is  fortified  by  an  essential  oil.  as  it  is  under  the  forin 
of  absinthe,  the  effects  are  correspondingly  nullified.  Acute  alcoholism, 
or.  delirinni,  trenieiLs,  does  not  properly  come  under  the  head  of  insanity, 


96  A  SYSTEM  OF  LEGAL  MEDICINE. 

and  is  not  ordinarily  so  considered.  Its  freqnent  jDresentation  as  an  ex- 
cuse for  crime  meets  with  no  favor,  for  the  law  nsnally  ver}'  projierly 
holds  that  when  an  irresponsible  state  is  voluniarihj  produced,  the  indi- 
vidual is  liable  for  his  acts ;  yet  there  are  periodical  drinkers  whose  cul- 
pability is  certainly  deserving  the  leniencj^  of  juries.  To  this  class  belongs 
the  dipsomaniac,  whose  excesses  are  separated  by  periods  diu'ing  which  his 
conduct  is  irreproachable,  and  when  he  does  lapse  it  is  under  the  domi- 
nance of  an  insane  appetite.  The  mental  disturbance  of  acute  alcoholism 
is  the  lively  deliiium,  visual  hallucinations  and  delusions,  motor  activity, 
and  exhaustion. 

Chronic  aJcoliolic  insanity  is  manifested  by  a  train  of  progi'essive  symp- 
toms of  mental  degeneration  which  vaay  greatly.  The  most  important 
indication  of  the  prolonged  saturation  of  the  nervous  organs  with  alco-. 
hoi  is  an  impairment  and  weakening  of  the  mental  functions,  conspicuous 
among  which  is  the  moral  enfeeblement.  The  familiar  change  of  char- 
acter is  one  that  needs  no  description.  Nervous  irritability,  the  disregard 
of  obligation,  untidiness  in  dress,  sexual  perversion,  lost  sense  of  honor, 
manifested  in  lying  and  other  directions,  indifference  as  to  domestic  and 
social  duties,  are  all  every-day  results  of  a  prolonged  abandonment  to 
drink.  Advanced  grades  of  deterioration  are  manifested  in  the  appear- 
ance of  delusions,  such  grave  indications  of  decay  as  continued  depressed 
or  excited  states,  and  a  dementia  which  resembles  paretic  dementia. 

The  delusions  of  the  chronic  alcoholic  are  usually  those  of  persecu- 
tion and  suspicion.  One  quite  characteristic  is  that  entertained  by 
married  men  regarding  the  chastity  of  their  wives.  Persistent  halluci- 
nations of  hearing  are  also  present,  are  always  of  a  distressing  char- 
acter, and  the  patient  may  be  urged  to  suicide  by  imaginary  voices; 
-while  sensory  hallucinations  which  originate  in  the  abdominal  organs  or 
those  of  generation  lead  him  to  believe  in  the  occurrence  of  some  horrible 
mutilation,  and  often  in  the  removal  of  the  testes. 

''  Hallucinations  prevailed  in  22.7  percent,  of  the  recurrent  cases  of 
the  criminal  insane  collated  by  Lewis  in  which  alcoholism  largely  figured. 
The  visual  and  aural  in  about  the  same  proportion,  and  both  associated  in 
;a  few  cases ;  olfactory  hallucinations  or  illusions  were  seldom  noted,  and 
gustatory  were  notably  absent.  Delusions  occur  in  at  least  half  the 
cases  (53  percent.).  Both  hallucinatory  and  delusional  states  vary  with 
the  proximate  cause  of  the  outbreak :  if  alcoholic  excess  enters  largely 
into  the  causation,  we  may  anticipate  associated  ideas  of  self-importance, 
rank,  power,  wealth,  and  suspicion  of  perfidy  upon  the  Y*avt  of  those 
around  him.  One  patient  receives  a  nighth'  visit  from  his  satanic  majesty ; 
another  sees  imps  around  him,  hears  voices  beneath  the  floor,  the  noise 
and  rumble  of  machinery,  which  his  morbid  imagination  frames  into 
some  idea  of  coming  torture.  Another  patient,  twenty-eight  years  of 
age,  addicted,  to  intemperance  in  drink,  and  the  subject  of  a  serious 
cranial  injury  in  youth,  calls  hhnself  Sir  Roger  Tichborne,  and  accuses 
his  relatives  of  filling  his  bedroom  mth  the  vapor  of  cliloroform.  An- 
other young  alcoholic  subject  owns  property  "to  the  value  of  thousands 
a  year,"  has  extraordinary  muscular  power,  and  can  "  walk  eighty  miles 
a  day  continuously"  (loe.  cif.,  p.  215). 

Such  physical  symptoms  as  motor  incoordination,  trembling  of  the 
hands,  facial  muscles,  lips,  and  tongue,  are  common.  The  tremor  of  the 
hands  is  worse  in  the  early  part  of  the  day.     After  a  time  an  actual 


INSANITY  IX  ITU  ilKIH CO-LEGAL  BEARINGS. 


97 


paralysis  of  tlie  lower  part  of  the  bod}^  develops  itself,  and  iw^y  be  at- 
tended by  eraitips,  deep  pains,  sug'^estive  neuritis,  or  by  an  incoordina- 
tion, with  plantar  anaesthesia,  wliieli  often  leads  to  the  mistaken  diajrnosis 
of  loeoniotor  ataxia.  This  anaesthesia  is  pretty  general,  espeeiallj'  if  the 
<}onsuniption  of  alcohol  is  constant,  and  points  to  a  gradual  inliamniation 
not  only  of  the  large  nerve  trunks,  but  of  the  ultimate  filaments  as  well. 
The  skin  of  the  legs  is  apt  to  be  "shiny"  and  smooth.  Although  some 
-of  these  symptoms  may  improve  or  disappeai-  if  the  alcohol  be  with- 
drawn, there  can  be  only  one  ending  as  a  result  of  continued  indulgence. 

The  "  paresis  "  of  alcohol  is  very  nmcli  like  classical  paretic  dementia, 
the  delusions  of  grandeur,  pei'haps,  being  more  constant  in  the  former, 
and  the  delusions  of  suspicion  more  systematized.  The  tremor  is  coarser 
and  more  general  in  alcoholic  paresis.  The  gastritis  of  alcoholic  paresis 
is  of  course  not  found  in  the  other  insanity,  nor  is  the  anaesthesia  or  the 
fulgurating  pains  (except  in  the  ascending  form  which  follows  tabes 
spinalis).  Paretic  dementia  is  not  modified  by  treatment,  as  is  the  variety 
under  consideration.* 

The  medico-legal  importance  attached  to  all  forms  of  alcoholic  insan- 
ity is  fully  proved  by  the  frecpiency  of  cases  where  it  is  the  issue.  It  is 
-alleged  as  a  cause  of  testamentary  weakness,  or  in  fact  where  the  assump- 
tion of  an  hnproper  obligation  arises ;  and  the  protection  of  the  courts  is 
often  sought  for  individuals  who  are  said  to  be  incompetent.  In  all  of 
these  cases  the  question  of  the  existence,  degree,  and  duration  of  the 


*  Alcoholic  InacmHii  complicutcd  iritli  Fa- 
alysis. 

Headache. 

Active  halhicinations  affecting  all  tlie 
senses;  disordered  vision  (illusions). 

Delirious  conceptions  depending  upon 
liallueiuations ;  ideas  of  persecution,  ten- 
dency to  suicide,  evil  instincts,  conscious- 
ness of  degradation. 

Embarrassed  speech,  depending  some- 
what upon  fear,  upon  startings  of  the 
muscles  of  the  face,  and  especially  upon 
tremulousness  of  the  tongue. 

Feebleness,  little  marked,  of  the  infe- 
rior members ;  equal  on  both  sides. 

Trembling  of  the  hands  and  the  arms, 
more  marked  in  the  morning ;  formica- 
tions, cramps,  and  startings  of  the  tendons 
of  the  forearm. 

Pupils  nearly  always  dilated. 

Ana?sthesia  of  the  extremities  of  the 
limbs,  extending  generally  in  the  superior 
limbs  to  the  elbow,  and  in  the  inferior  to 
the  knee. 

Sleep  disturbed  with  dreams ;  sometimes 
sleeplessness. 

Diminution  of  appetite,  acid  eructations, 
vomiting-  of  mucus  in  the  morning. 

Diminution  of  the  generative  functions  ; 
frigidity. 

Readily  cured  or  modified. 

Occasional  supervention  of  (Icliriiini  trc- 
meiis. 


Paretic  Dementia. 

Generally  no  headache. 
Enfeeblement    of    the    understanding; 
rarely  hallucinations. 

Ideas  of  grandeur  and  self-importance. 


Embarrassed  speech,  depending  upon 
feebleness  of  the  cojieeptions  and  paral- 
ysis of  the  muscles  of  the  face. 

Feebleness  of  the  inferior  members, 
more  marked  generally  upon  one  side  than 
the  other. 

Nothing  appreciable  in  the  superior 
limbs  ;  sometimes  default  of  coordination. 


Pupils  often  mieqiual.  often  contracted. 
Sensibility  normal,  or  obtuse  over  the 
whole  surface. 


Sleep  generally  normal. 
Appetite  augmented. 

Augmentation  of  the  generative  func- 
tions. 

Progress  of  the  disease  ordinarily  rapid, 
always  fatal. 

Tendency  to  congestions  and  to  epilepti- 
form attacks. 


98  -i    SYSTEM   OF  LEGAL    MEDICLXE. 

cause  is  to  be  determined,  as  "welL  as  Trhetlier  tlie  alleged  iiTesponsibility 
is  due  to  a  comparatively  rapid  toxic  origin,  or  the  mental  distui-bance 
masks  a  gradual  and  permanent  disorganization.  The  connection  of 
alcoholism  "v^-ith  insanity  at  Charenton  has  been  studied  by  Thorneuf 
{Annales  Medico-PsijclwJogique,  1859,  p.  365),  who  thus  classifies  alco- 
holism : 

1.  Aciite  alcoholic  intoxication,  in  which  the  effect  is  always  immedi- 
ately Knked  to  the  cause,  and  the  diu-ation  of  which  is  dependent  upon 
the  existence  of  the  cause. 

2.  Subacute  alcoholic  intoxication,  supervening  to  the  immediate- 
action  of  the  cause,  usually  melancholic  in  character. 

3.  Chi'onic  alcohohc  intoxication,  which  results  in  organic  changes 
in  the  brain  and  nervous  system,  with  accompanying  insanity-. 

Of  350  lunatics  treated  in  Charenton,  when  Dr.  Thorneuf  was  an  in- 
terne, the  insanity  in  102  cases  was  due  to  alcohol :  of  these.  15  percent, 
were  of  deliiimn  tremens  ;  6  j^ercent.  were  of  di'unken  mania  :  1  percent, 
was  of  congestive  mania :  3-4  percent,  were  of  paretic  dementia  ;  -4  j)ercent. 
were  of  folk  circnlaire  ;  2  percent,  were  of  dementia;  and  the  remainder- 
presented  epileptiform  con\*ulsions  and  anomalous  psychical  symptoms. 


IX.   3IELAXCH0LIA. 

This  most  familiar  and  common  f onn  of  insanity  is  classified,  with 
regard  to  its  duration  and  clinical  featui-es,  as  ac-ute  and  chronic,  and 
clinically  as  simple  meJancJiolia ;  melancholia  apathetica  or  afonifa,  or 
stuporous  melancliolia  ;  and  melanclwlia  agitata,  or  anxious  melancliolia. 

Simple  melancholia  is  a  state  which  is  accompanied  by  intense  de- 
pression, mth  painful  delusions  of  a  fixed  but  limited  character,  usually 
consisting  of  those  which  imply  complete  dejection  and  hopelessness^ 
and  may  lead  the  person  who  entertains  them  to  commit  suicide.  Through 
a  condition  of  impaii-ed  organic  memory  there  may  be  more  or  less  loss 
of  identity,  or  a  false  belief  as  to  the  identity  of  another.  Among  the 
commoner  delusions  that  are  tenaciously  held  is  that  of  financial  or  moral 
ruin.  The  patient  may  in  reality  be  a  very  rich  or  a  very  good  man, 
yet  he  asserts  that  he  is  going  to  the  poorhouse  or  is  in  danger  of  eternal 
imnishment.  Such  a  form  of  melancholia  is  of  slow  development,  and 
is  preceded  b}'  continued  ill  health,  loss  of  appetite  and  insomnia,  which 
becomes  more  and  more  profound  unless  reheved.  A  natiu-ally  happy 
and  joyous  person  becomes  sad,  reserved,  and  takes  little  interest  in  her 
surroundings.  There  maj^  be  an  over-sensitiveness  and  a  sense  of  per- 
sonal shortcomings  and  a  feeling  of  self -depreciation ;  the  patient  is 
tortured  by  doubts  regarding  her  rehgious  ^iews  and  her  fitness  for  asso- 
ciation with  others.  She  may  imagine  that  she  has  committed  some 
unpardonable  sin,  or  that  she  is  beyond  help.  She  will  not  go  to  the 
communion-table,  behe\'iug  her  presence  there  will  pollute  those  whom 
she  may  meet;  and  one  who  has  led  a  blameless  and  piu-e  life  may  con- 
sider herself  the  lowest  of  women.  In  other  cases  the  depression  exists- 
in  regard  to  more  worldly  things :  the  merchant  will  beheve  that  he  is 
bankrupt,  that  he  is  dishonest,  or  that  he  is  the  special  object  of  con- 
tempt among  his  business  associates. 

The  patient  is  slow  in  his  actions,  and  moves  sluggishly  and  with 


INSANITY  IN  ITS  MEDICO-LKCAL   JlEARINCiS. 


99 


Fig.  3:3.     (Shaw). 


reluctance.  It  is  with  difficulty  that  liis  att(nitioii  can  he  aroused,  and 
that  his  mind  may  be  hxed  for  a  slioi-t  time  upon  some  g-iven  sul)jeet. 
If  an  effort  is  mad(^  to  reassui-e  liim  lie  is  incredulous  and  as  dejected  as 
•ever.  Tlie  appearaii(;e  of  melancholia 
of  all  kinds  is  characteristic,  and  the 
physical  symptoms  are  those  indicat- 
ing^ the  existence  of  anaGmia  (Fig.  23). 
The  skin  is  oftc^n  harsh,  diy,  and  jiale, 
as  are  the  mucous  membranes.  The 
whites  of  the  eyeballs  are  of  a  dull, 
flat  wliite ;  the  pupils  are  dilated  and 
slug'gish.  The  inner  surface  of  the  lids 
shows  an  absence  of  healthy  vascular 
.supply.  The  tongue  is  flabby  and  in- 
dented, and  the  breath  is  vinous  or  bad. 
The  finger-tips  are  usually  rough,  and 
there  are  hang-nails,  which  are  due  to 
■defective  nutrition  and  tlie  constant 
haliit  of  j)ickiiig.  The  extremities  are 
■cold  and  clammy,  with  ])ooy  reaction 
to  rubbing.  The  hair  is  damp  and 
limp.  Occasionally  the  patient  will 
pluck  out  the  eyelids  or  the  haii*  from 
the  head,  with  resulting  deformity  and 
highly  characteristic  change  in  appear- 
ance.    Respiration  is  apt  to  be  slow, 

as  is  the  pulse.  The  patient  may  urinate  copiously  when  excited  or  espe- 
cially anxious,  and  the  excretion  will  be  of  light  color  and  low  specific 
gravity.  Constipation  is  also  characteristic  of  melancliolia.  The  surface 
and  the  deep  temperature  are  lowered,  the  latter  being  often  subnormal 
for  long  periods. 

Many  patients  complain  of  occipital  or  vertical  pain  and  the  sense  of 
pressure,  which  are  probably  due  to  cerebral  amemia. 

Hypochondriacal  melancholia  is  a  persistent  form  of  disease  which 
may  be  the  outcome  of  ordinary  hj^iochondriacal  introspection  ;  the  sub- 
ject ultimately  beheving  that  a  serious  and  material  alteration  has  taken 
place  in  his  internal  organs — that  his  brain  has  been  removed,  or  that  his 
bowels  are  impervious,  that  his  food  ^'passes  through  him,"  that  his 
■semen  is  constantly  escaping,  or  that  the  testicles  are  absent  or  that  he 
is  impotent.  His  false  beliefs  may  range  from  simple  systematized  delu- 
sions to  those  of  the  most  improbable  and  unsystematized  nature.  In 
some  cases  the  condition  resembles  a  primary  delusional  insanity. 

Graver  varieties  are  stuporous  melancholia  and  melancholia  agi= 
tata.  In  the  former  the  atony  and  depression  may  be  extreme  in  tlieii' 
depth.  The  patient  can  be  aroused  with  the  greatest  difficulty,  and  im- 
mediately resumes  his  constrained,  fixed  position  and  absolute  silence.  He 
often  sits  for  long  periods,  occasionally  sighing,  and  his  external  appear- 
ance is  indicative  of  his  mental  torpor  and  bcAnlderment.  Such  patients 
will  for  hours  retain  morsels  of  food  between  then*  teeth  and  cheeks, 
being  too  indifferent  to  masticate  or  swallow ;  at  times  forcible  feeding 
is  absolutely  necessary.  Occasionally,  especially  in  3'outliful  subjects, 
there  will  be  a  tendency  to  catalepsy,  the  muscles  of  the  extremities  being 


100  ^   SYSTEJI  OF  LEGAL   ilEDLCLNE. 

at  times  so  rigid  that  it  is  possible  to  put  the  members  in  constrained 
positions  which,  are  maintained  for  a  long  time.  The  profound  depres- 
sion is  sometimes  varied  by  fitful  flashes  of  intelligence  or  some  impalsiv& 
act,  -^'hich  is  as  likely  as  not  to  be  siucidal.  These  patients  upon  recovery 
are  able  to  recall  the  delusion,  and  its  influence  which  has  possessed  them. 

Melancholia  agitata  or  anxious  melancholia  is  one  in  which  excite- 
ment plays  a  part.  The  patient  is  always  tortured  by  some  distressing^ 
delusion,  with  attendant  painful  emotions.  Restlessness;  "^dolence,  and 
often  suicide  or  self -mutilation  are  exhibited  or  resorted  to.  The  patient 
is  active  by  day  as  well  as  night,  can  be  taken  care  of  only  with  the 
greatest  difficidty,  and  wears  himself  out  in  useless  effort.  Delusions, 
hallucinations,  and  illusions  are  ever  ^^resent,  and  auditory  hallucinations 
are  the  most  torturing.  The  patient  is  told  to  do  certain  things  by  voices 
that  come  from  water-pipes  and  holes  in  the  wall.  Visual  and  sensory 
hallucinations,  too,  add  to  his  mental  terror.  His  bed  swarms  with  im- 
aginary vermin.  If  he  be  suspicious  that  he  has  been  poisoned,  he  will 
make  more  or  less  successfid  efforts  to  vomit,  and  call  attention  to  the 
escape  of  the  worms  and  "  microbes "  that  he  throws  up  or  the  snakes 
that  crawl  over  the  floor.  In  some  ways  the  delirium  of  acute  alcoholism 
is  some  tunes  suggested,  at  others  it  approaches  the  excitement  of  mania; 
but  in  the  former  there  are  actual  persecutory  delusions  and  in  the  lat- 
ter there  is  incoherence,  due  to  the  rapidity  of  outside  stimulation,  Avhich 
reflects  the  elated  and  pleasui-able  state  of  the  emotions.  There  is  rarely 
any  disposition  to  the  infliction  of  injm-y  in  melancholia,  except  so  far  as 
suicidal  attempts  are  concerned.  These  are  common,  and  the  results  of 
the  hopeless  delusions  and  hallucinations. 

So  far  as  the  physical  disorders  relate  to  the  mental  state  it  is  the 
fact  that  there  is  much  more  general  constitutional  distiu'bance  with 
anxious  melancholia  than  any  other  form.  Some  of  it  is  due  to  want 
of  sleep,  and  to  the  attempt  at  ^'oluntary  starvation  which  springs  from 
the  delusion. 

Chronic  melancholia  is  the  natui'al  outcome  of  a  continued  depres- 
sion which  need  not  necessarily  end  in  dementia,.  Sometimes,  esjjecially 
in  the  sexual  forms  in  women,  the  chronicity  is  attended  mth  a  great 
deal  of  reasoning  acuteness,  and  what  Eji'chhoff  calls  a  folie  raisonuanfe 
in  a  melancholic  form,  -Rdth  alternate  depression  and  angry  excitement. 
Melanchoha  is  often  ciu-al>le.  The  fii'st  danger  of  exhaustion  from  star- 
vation is  the  only  one  likely  to  Ining  an  early  fatal  termination,  except 
it  may  be  suicide  or  intercurrent  disease.  If  the  patient's  disease  lasts 
one  year  it  is  apt  to  he  permanent  and  incurable.  When  it  originates  at 
periods  of  sexual  development,  such  as  pubert3^  at  childbirth  or  the  cli- 
macteric epoch,  it  is  rather  apt  to  b^  obstinate.  This  is  especially  true  of 
the  puerperal  form. 

X.    3IANIA. 

Mania,  like  melancholia,  is  an  acquired  insanity,  though  under  certain 
conditions  it  may  symptomatize  both  evolutional  and  involutional  insan- 
ities. So  far  as  its  duration  is  conc(^rned,  it,  like  the  depression  psychosis, 
may  be  either  acute  or  chronic.  The  term  suhdcnfe,  sometimes  used,  has, 
I  think,  no  clinical  value.  It  is  eminently  a  mental  disorder  of  expan- 
sion, and  is  characterized  by  excitement  of  greater  or  less  violence  and 


IXSANITY  JN  ITS    MEDICO-LEGAL   BEARINGS. 


101 


coiiljiiuiince.  Like  mcL-UK'liolia,  it  is  apt  if  not  cured  to  end  in  termiuid 
dementia.  The  emotional  activity  and  intelle(;tual  exaltation  are  niani- 
fe«t(!d  in  a  rapid  ilow  of  ideas,  which  are  not  inhibited,  and  tin;  result 
is  incoherence.  Acute  mania  is  often  of  (juite  sudden  development, 
thoiig'li  usually  the  way  is  paved  by  some  decline  in  the  general  health. 
In  the  cases  that  usually  come  under  notice  a  histcny  of  alteration  in 
mental  health  is  evinced  by  an  exhilaration  and  liveliness  which  con- 
trast with  the  ordinary  habits  of  the  patient.  The  apparently  increased 
mental  activity  is  disorderly,  and  the  exercise  of  intellectual  vigor  sj)as- 
modic.  His  self-satisfaction  and  sense  of  importance  prompt  him  to 
enter  into  schenu's  moi-(;  or  less  wild,  his  generosity  is  exuberant,  and  he 
makes  the  grandest  promises,  without  any  idea  as  to  how  he  shall  fidhll 
them.  If  he  is  crossed  or  doubted  his  anger  is  quickly  aroused,  Init 
short-lived,  and  the  affront  is  forgotten  immediately.  His  mind  seems 
to  be  a  kaleidoscope  of  ever-changing  ideas,  which  later  become  more 
and  more  confused.  He  is  restless,  forgets  obligations  and  appoint- 
ments, sits  up  until  late,  and  sleeps  but  for  an  hour  or  two,  and  after- 
ward not  at  all.  He  gesticulates, 
and  his  manner  is  hurried  and 
impetuous.  His  letters  rellect  his 
tops3^-turvy  state  of  mind  and  re- 
fer to  his  schemes.  These  are 
often  innumerable,  and  he  writes 
to  every  one  he  has  heard  of. 
The  telegraphic  wire  is  kept  busy 
with  irrelevant  or  unnecessary 
messages.  His  dress  reflects  his 
condition,  for  he  is  slouchy,  and 
his  clothes  are  carelessly  put  on 
and  often  unbuttoned.  Some- 
times he  orders  and  wea.rs  gar- 
ments that  are  extravagant  in 
color  and  shape,  and  affects  a  style 
that  brings  him  into  notoriety. 
His  features  now  indicate  the 
excitement  under  which  he  la- 
bors, for  his  facial  muscles  twitch, 
his  eyes  are  prominent,  his  face 
is  flushed,  and  his  pupils  are  di- 
lated and  mobile.  The  patient 
will  bus}^  himself  doing  and  un- 
doing, fussing,  and  arranging 
and  rearranging  furniture,  clothes,  or  other  tilings.  A'arious  moral 
changes  appear  in  conversation  and  conduct.  These  vary  greatly,  and 
the  commission  of  shameless  acts,  the  making  of  indecent  proposals, 
or,  at  a  later  period,  when  the  incoherence  and  confusion  prevail,  the 
defilement  of  himself  with  faeces,  are  common  evidences  of  loss  of  con- 
trol or  evidences  of  sexual  irritation.  As  the  psychosis  becomes  more 
and  more  pronounced,  the  patient  becomes  nK)re  frivolous  in  dress  or 
absolutely  indifferent.  He  occasionally  decoi-ates  himself  with  fantastic 
objects.  One  of  my  patients,  who  was  the  suliject  of  chronic  mania  and 
had  acute  exacerbations,  was  in  the  habit  of  putting  on  a  white  satiu 


Fig.  :.'t.     1 1 1 


102  ^   SYSTEM  OF  LEGAL  MEDICINE. 

ball-dress  when  she  arose,  and  loading  her  neck  and  wrists  with  dia- 
monds. She  would  give  herself  up  to  amorous  thoughts  and  conversa- 
tion, and  write  erotic  letters  and  poetry  to  men  she  knew  but  slightly  or 
not  at  all.  So-called  kleptomania  is  apt  to  be  an  incident  of  such  develoj)- 
ment,  and  it  differs  from  the  kind  due  to  imperative  concepts  by  reason 
of  the  fact  that  in  this  disease  the  intellect  is  disordered.  The  thefts 
are  of  all  kinds,  and  bits  of  worthless  rag,  keys,  l^its  of  glass,  or  trifling 
objects  are  stolen  and  secreted  very  much  as  a  magpie  would.  The 
patient  is  also  at  times  prone  to  indiilge  in  low  vituperation,  and  makes 
use  of  oaths  and  expressions  which  are  so  foreign  to  the  normal  moral 
integrity  as  to  make  every  one  wonder  where  they  were  learned.  Young, 
innocent  girls  will  repeat  ford  words  of  the  gutter  and  cannot  be  re- 
strained. 

When  the  disease  has  increased  to  the  point  where  the  excitement  is 
intense  and  the  patient  is  incoherent,  the  hallucinations,  illusions,  and 
delusions  are  dominant  and  so  active  as  to  suggest  delirium.  All  forms 
of  intense  motor  acti\it3^  make  themselves  apparent  in  violent  muscular 
movements  of  various  kinds — cries,  shouts,  loud  singing,  laughing — or  in 
automatic  movements  which  are  repeated  for  a  long  time.  Sometimes  the 
patient  declaims  energetically,  flourishing  his  arms,  and  walks  bombastic- 
ally up  and  down.  Sometimes  there  is  an  exaggerated  di-amatic  power 
of  expression,  a  simple  act  being  performed  in  a  grandilocpient  way. 
He  decorates  liimself,  as  well  as  his  room,  with  odd  objects,  mixes  up  his 
food  in  a  disgusting  mess,  and  eats  ravenously.  His  hallucinations  fol- 
low one  another  with  great  rapidity,  and  he  has  frequent  conversations 
with  imaginary  people  he  sees,  which  are  not  interrupted  b}^  the  casual 
entrance  of  a  visitor.  Sometimes  the  illusions  result  in  a  loss  of  identity, 
the  patient  believing  the  visitor  to  be  a  relative,  a  lover,  or  some  improb- 
able person.  He  is  shoWered  with  kisses  or  is  the  subject  of  demonstra- 
tions of  the  most  marked  kind. 

Local  anesthesia  or  hypera3sthesia,  the  former  of  which  consists  in  in- 
sensibility to  extremes  of  temperatiu'e,  and  the  latter  to  headache  and 
subjective  discomfort,  may  be  mentioned  as  symptoms.  This  heighten- 
ing of  sensation  may  be  the  origin  of  olf  active  hallucinations,  which  are 
present  in  about  fiftj^  percent,  of  all  cases.  Fig.  24  represents  very  well 
the  expression  of  exaltation  so  characteristic  of  this  form  of  insanity. 

Mania  is  nearl}^  always  preceded  by  some  depression,  and  the  activity 
of  mental  operations  which  is  sometimes  evinced  by  a  revived  acuteness 
of  memory  must  be  looked  upon  with  suspicion.  After  the  continuance 
of  the  acute  condition,  whieli  is  expressed  by  the  impulsive  conduct  and 
is  variable  in  dm-ation,  we  find  convalescence  and  ultimate  eui-e,  or  a 
clironic  mania  or  terminal  dementia.  The  duration  of  cases  which  are 
to  get  M^ell  is  variable,  the  time  varying  from  a  few  weeks  to  a  year. 
Stearns  says  that  when  a  case  has  passed  the  twelfth  month  it  is  to  be 
regarded  as  chronic.  This,  I  think,  is  the  generally  accepted  conclusion, 
and  a  safe  prediction.  When  a  case  becomes  chronic  the  mental  condi- 
tion is  often  one  of  extraordinary  evenness,  though  all  sorts  of  disorderly 
manifestations  may  occur  from  time  to  time.  The  chronic  maniac  of 
asylums  is  usually  a  moderately  noisy,  active  patient,  who  always  has  a 
collection  of  rather  imiform  delusions  and  hallucinations  which  are  eas- 
ily evoked,  and  the  former  tincture  the  manner  and  are  shown  in  dress. 
There  are  other  patients  whose  unsystematized  delusions  become  more 


IXSAXITY  IX  ITS   MKDIVO-LKUAL    BKARIXGS.  103 

and  more  (lisoi\t>;uiized  and  absurd,  and  whose  incoherence  is  not  con- 
fined to  any  ])art  of  the  day  or  night.  Some  who  present  the  incurable 
form  of  this  disease  are  liarndess  enough,  and  are  capal>le  enough  to  do 
farm-work  requiring  little  or  no  individual  exercise  of  judgment.  Ac- 
<M)rding  to  the  statistics  of  the  Hartford  Reti-eat  it  would  appear  that 
52.1+  percent,  of  acute  cases  recovered  and  20.2+  percent,  were  im- 
proved. Of  the  clu'onic  cases  27.4  +  pei'cent.  improved  ov  recovered.  Of 
<',ourse  the  progression  depends  ui)on  the  frequency  and  extensive  vio- 
lence of  the  active  congestion  of  the  brain  and  the  causation  of  organic 
■changes. 

Typhomania  {delire  aign)  is  a  form  of  intense  excitement  of  sudden 
origin,  often  due  to  shock  or  fright,  and  is  characteiized  by  a  complete 
mental  blotting  ont,  or,  as  Lewis  calls  it,  mental  oblivion.  There  seem 
to  be  absolute  incoherence,  babbling  and  confusion,  and  physical  signs 
•of  extreme  exhaustion  from  which  it  gains  its  name :  these  are  a  rise  of 
temperature,  great  exhaustion,  sordes  upon  the  teeth,  scanty  urine,  a 
glazed  or  brown  tongue,  involuntai-y  stools,  etc.  The  patient  fails  from 
the  fii'st,  and  usually  succumbs  in  a  short  time. 

XI.   PUERPERAL  INSANITY. 

Puerperal  insanity  is  a  ps_ychosis  of  women,  having  relation  to 
child-bearing,  as  its  name  implies,  and  is  connected  with  the  accom- 
plishment of  delivery.  It  is  sometimes  dependent  upon  exhaustion 
or  septic  poisoning,  or  both,  and  develops  in  from  one  to  several  weeks. 
The  insanity  of  early  appearance  is  usually  maniacal.  The  patient  does 
not  sleep,  but  manifests  great  incoherence  and  violence.  She  smears  her- 
self with  fecal  matter ;  curses,  and  manifests  great  motor  activity.  Ex- 
haustion is  ra]iid  and  great,  and  death  may  even  follow  in  a  week  or  two. 
A  later  form  appears  in  a  month  or  more,  and  is  melancholic  in  chai-acter. 
The  woman  usually  develops  an  indifference  or  actual  hatred  toward  her 
■child,  which  she  may  murder,  while  the  tendency  to  suicide  is  by  no 
means  unusual.  Sometimes  there  may  be  no  indication  of  the  real  state 
until  a  crime  of  violence  is  perpetrated.  This  is  especially  the  case  in 
remote  and  isolated  regions  of  the  country,  where  all  the  subtle  indica- 
tions of  growing  mental  weakness  are  disregarded  and  looked  upon  as 
■evidences  of  "  ugliness."  In  this  connection  an  abstract  from  the  con- 
fession of  a  puerperal  patient  who  killed  her  child  may  be  presented. 
This  patient  was  tried  for  her  life  and  sent  to  the  Utica  Asylum,  nar- 
rowly escaping  the  penalty  of  the  law.  The  case  is  suggestive,  because 
it  shows  the  existence  of  imperative  concepts  and  perhaps  auditory  hal- 
lucinations. 

The  subject  was  a  young  woman  (see  vol.  i.,  p.  194,  Figs.  3G  and  37) 
who  less  than  one  year  after  her  marriage  killed  her  child.  During  her 
imprisonment  she  prepared  the  following  statement.  The  first  part, 
which  is  omitted,  deals  with  her  early  nuirried  life  and  her  disagreement 
with  her  husband,  who  selfishly  ignored  her  real  state  of  mental  dis- 
order : 

I  did  not  ■want  to  livp  any  longer;  it  seemed  as  if  I  liad  no  friends,  as  if  all  were 
against  me.     Throngli  the  summer  these  spells  gained  upon  me;  would  walk  my  room 

nights  and  cry  as  if  my  heart  Avould  break.     M [the  hnshand]  -svould  lie  angry  with 

me  for  disturbing  his  rest.     He  said  at  one  time  "  he  thought  it  very  strange.     Some- 


104  A   SYSTEM  OF  LEGAL  MEDICINE. 

times  I  could  not  do  euoiTgh  for  him,  then  at  other  times  I  acted  as  if  I  hated  him."'' 

The  4th  of  July  we  went  to  O .     I  proposed  going,  as  we  had  not  been  away 

from  home  but  a  few  times  since  we  were  married ;  told  him  I  shoulet  enjoy  the  dance 
much  more  than  ever  before,  to  have  him  join,  as  it  was  no  comfort  for  me' to  go  when 
he  played.*  I  gave  him  money  enough  to  i^ay  the  bill,  as  he  would  not  have  went  if 
he  had  had  to  pay.  Mother  had  paid  me  at  different  times  for  helping  her,  and  out  of 
this  I  gave  him.  I  was  not  right  for  a  few  days  before  the  dance,  felt  very  strange, 
but  thought  I  might  feel  better  for  going,  but  did  not.  It  was  a  miserable  night  to 
me ;  going  home  I  wept,  felt  very  badly  all  that  day  and  night.   .  .   .  After  the  baby 

was  born  it  slept  vnth.  me  one  or  two  nights.     Then  I  remember  Mrs.  H .  my 

mother-in-law,  came  to  my  bed  and  took  the  child  away  from  me,  jaretending  that  she 
was  afraid  M or  myself  would  accidentally  hurt  it,  as  we  were  not  used  to  chil- 
dren. I  was  afraid  of  her,  and  dare  not  speak,  and  let  the  child  go.  I  remember 
when  my  milk  came  she  seemed  determined  not  to  have  it  nurse.     "Whenever  Mrs. 

D or  Mrs.  A tried  to  have  him  nurse,  she  was  as  angi-y  as  could  be,  and  said 

she  thought  they  would  kill  the  child.  She  never  tried  to  have  him  nm-se  me.  "\Mien- 
ever  I  would  hold  him  and  rock  him,  she  always  seemed  displeased,  and  would  say  it 
would  get  him  into  bad  notions ;  so  I  dare  not  do  anything  with  him — hardly  hold 
him;  she  seemed  to  want  to  take  all  the  care  of  him.    "\Vhen  he  was  about  a  week  old 

A H and  wife  came  one  day,  and  as  I  was  not  able  to  do  anj-thing  I  held  him 

most  of  the  forenoon.     Mrs.  H hinted  about  it  several  times,  saying  that  was 

what  spoiled  him.  A  day  or  two  after  this  I  began  to  have  such  horrible  feelings.  It 
seemed  that  as  if  he  or  I  could  die  it  would  be  much  better,  as  there  was  no  comfort 
for  me  in  the  world.  Something  seemed  to  say  to  me,  "It  must  be  done.''  One  day, 
as  I  was  Ij'iug  on  the  bed  beside  him,  the  thought  suddenly  came  to  me  to  strangle 
him  by  pressing  the  clothes  tight  about  his  neck.     I  did  so,  then  got  up  and  left  him. 

Mrs.  H soon  went  after  him  to  feed  him.     She  thought  he  was  dead  ;  she  seemed 

much  excited.  I  remember  I  was  sitting  by  the  stove  as  she  brought  him  out,  and 
remember  her  saying  he  was  as  limpsy  as  could  be.  Afterward  she  told  the  men  that 
the  clothes  must  have  got  over  his  face.  About  a  week  after  I  tried  again,  in  my 
anguish  and  sorrow,  to  end  his  days  by  smothering,  but,  as  before,  he  come  to.  It 
seemed  as  if  it  must  be  :  something  constantly  seemed  to  say  to  me,  "It  must  be  done  : 
he  must  die  or  yom'self."  .  ,  . 

A  few  days  after  I  was  confined  Mr.  H— —  came  to  the  bedi-oom  door  and  asked 
me  what  was  the  matter,  as  he  had  seen  from  the  kitchen  that  I  was  crying.     I  don't 

know  what  reply  I  made.     Before  the  E dance,  also  the  L dance,  I  felt  very 

strange  and  cried.     M said  '-'I  was  only  mad  because  he  was  going."'     The  only 

objection  I  ever  had  to  his  playing  was  I  never  could  go  vrith  him  but  thei-e  was 
trouble.  He  was  jealous  of  me  without  any  cause  whatever.  He  told  me  before  we 
were  married  that  after  we  were  married  he  never  should  play  for  another  dance ;. 
that  he  did  not  want  to  play  and  was  not  obliged  to  for  a  living,  and  wanted  to  give 
it  up. 

The  first  I  knew  about  that  box  of  poison  t  M called  my  attention  to  it  when 

we  were  first  there.     It  was  in  a  small  cupboard  in  the  kitchen.     He  took  it  from  the 

cupboard,  saying  S 's  folks  had  left  it ;  also  said  that  a  little  of  it  would  soon  finish 

any  one.  From  that  moment  the  thought  went  with  me  that  I  could  take  a  dose  my- 
self, or  give  it  to  the  baby,  and  Ave  would  be  done  suffering.  I  tried  to  drive  this 
thought  away,  but  could  not.  It  did  not  seem  wrong  or  as  if  it  would  be  wicked.  It 
seemed  as  if  it  must  be  :  that  voice  or  voices  constanthj  seemed  to  say  to  me,  "It  must 
be  done  ;  it  must  be  done."  One  day  when  I  was  alone  I  had  such  horrible  feelings  ; 
that  voice  sounded  so  loud,  saying  "those  words,  "It  must  be  done,"  that  I  took  the 
box,  and  was  just  going  to  take  a  dose  myself  when  old  Mrs.  B came  in.  I  re- 
placed it,  and  talking  with  her  seemed  to  arouse  me.  After  she  had  gone  I  shuddered 
to  think  how  near  I  had  come  to  death  ;  went  and  put  the  box  upon  a  high  shelf  in  the 
pantry  where  I  thought  I  would  not  be  apt  to  get  hold  of  it  when  I  had  those  spells. 

Told  M when  he  came  home  that  night  where  I  had  put  the  box,  as  I  was  afraid 

to  leave  it  in  its  former  place.     We  did  not  take  the  baby  with  us  when  we  went  to 

housekeeping.     I  did  not  want  to  take  it.     Mrs.  H seemed  willing  to  take  care  of 

it,  and  I  was  very  willing  she  should.     Wlien  at  H 's  I  preferred  doing  housework 

instead  of  taking  care  of  it  or  holding  it. 

The  Saturday  before  the  1st  of  April,  M and  myself  went  over  to  my  father's. 

*  The  husband  and  wife  were  hop-pickers  ;  he  played  the  A-iolin  at  eoimtry  dances, 
t  Box  of  "  Rough  on  Eats  "  with  which  she  poisoned  her  child. 


IXSANITY  IX  ITS  MKDICO-LKd.lL   JlJ'JAlilXGS.  105 

as  I  had  some  macliino-sowiiig  to  do.  While  there  I  ])og[in  to  have  siu-h  horrible  feel- 
ings— sueh  a  terrible  feeling  in  my  head — that  I  liardly  knew  anything.  Mother  tin- 
ished  my  sewing,  as  I  eould  not.  All  I  could  tliink  of  was  that  poison.  It  seemed 
stamp(Ml  up())i  my  mind,  and  those  voices  repeateil  again  and  again  tliosc:-  same  never- 
ceasing  words,  "It  must  be  done ;  it  must  be  done."  TJie  last  I  can  rememVjer  are 
those  words  ringing  in  my  ears.  Froin  that  time  until  the  1st  of  June  everything 
looks  dark  to  me,  and  do  not  have  a  distinct  remembrance  of  anything. 

During  this  time  slie  actually  forced  rat-poison  down  her  cliild's 
throat.  After  its  death,  even,  her  conduct  was  looked  upon  as  a  display  of 
simple  perversity,  and  in  most  matters  she  behaved  as  she  always  had. 


XII.   TRAUMATIC   INSANITY. 

Considerable  medico-legal  importance  is  attached  to  those  insanities 
that  follow  head  and  other  injuries ;  and  suits  for  damages,  though  not 
so  common  as  when  spinal  concussion  is  urged,  are  sometimes  brought. 
As  a  result  of  a  recent  or  ancient  blow  to  the  head,  or  other  exliibition 
of  force  that  may  result  in  what  is  known  as  commotio  cerehri,  we  are 
furnished  with  mental  disorders  of  a  more  or  less  serious  natm-e,  the 
mode  of  causation  of  which  has  been  before  alluded  to.  Such  distiu-bauces 
of  intellect  are  extremely  variable,  and  may  on  the  one  hand  consist  in 
temporary  confusion,  or  in  much  more  grave  and  lasting  psychoses  due 
to  degeneration.  Rigal  {Annales  (VHi/giene  Pnhlique,  April,  189-1-,  p.  340) 
has  recently  written  upon  the.  insanity  due  to  cerebral  commotion,  and 
says  that  the  important  forms  of  alienation  are  :  (1)  Reasoning  insanity, 
which  Trelat  calls  folie  Ii(cicle,  because  the  intellectual  faculties  are  gener- 
ally so  active,  but  there  is  a  perversion  of  the  moral  side  ;  (2)  monomania 
(paranoia)  of  brusque  development,  and  rapidl}^  enstiing  dementia;  (3) 
a  conf iisional  condition.  In  fact  this  author,  as  well  as  Magnan,  Ball,  and 
other  French  writers,  believes  that  there  is  hardly  a  form  of  mental  disease 
that  under  certain  conditions  cannot  be  produced  by  head-injury.  Under 
some  circumstances  a  sloAvly  forming  organic  insanity  follows,  which  may 
reseml)le  paralytic  dementia.  Spitzka  is  disposed  to  lay  stress  upon  the 
fact  that  the  subjects  Avho  are  most  likely  to  develop  this  kind  of  mental 
disease  after  injury  present  the  "  traumatic  neurosis,"  or  preparatory  basis. 
Such  a  foundation  exists  in  the  cases  where  there  is  a  hysterical  tendency, 
just  as  it  does  in  "railway  spine,"  and  a  psychosis  of  an  irregular  nature 
follows,  which  is  symptomatized  by  a  sensory  hyperaesthesia  and  motor 
weakness. 

In telleetual  changes  of  slow  growth  often  f oUow  slight  shocks.  These 
manifest  themselves  in  the  depai'ture  from  foi-mer  habits  and  tastes; 
moroseness  or  excitability,  innnoral  tendencies,  and  mental  weakness 
are  induced,  (lall  speaks  of  a  man  who  was  injured  by  a  falling  tile, 
which  penetrated  the  In-ain.  Before  the  accident  he  was  an  amiable,  steady 
man  ;  afterward  he  was  quarrelsome,  and  flew  into  a  rage  at  Little  things. 
"  W.  H.,  about  whom  I  was  consulted  some  time  ago.  was  a  steady  and 
respectable  tradesman  until  he  fell  from  some  steps  while  cleaning  a-  shelf 
in  his  own  shop,  and  was  stunned  for  a  few  seconds.  From  that  time  he 
underwent  a  change.  He  no  longer  att(Mul(>d  to  busin(^ss,  to  which  he 
had  been  f()rin(Mly  devoted  ;  he  speculated  and  lost  his  savings  ;  he  mani- 
fested antipathy  toward  his  wife  and  two  out  of  his  five  children,  and 


106  -^   SYSTEM   OF  LEGAL  MEDICINE. 

saw  liis  whole  family  reduced  to  penury  through  his  own  rashness  and 
neglect  without  displa^dng  any  compunctions.  When  complete  pecuniary 
ruin  had  been  effected  he  suddenly  became  himself  again,  and  resumed 
industrious  ways,  but  ever  since  he  has  had  attacks  of  restless  exeitabilitj^, 
with  hatred  of  his  wife  and  children,  twice  or  thrice  a  year.  He  is  at  all 
times  intelligent,  rational,  and  free  from  delusions,  and  when  at  his  best 
period  joins  his  relatives  in  deploring  the  sad  visitations  to  which  he  is 
liable."     (Browne.) 

Dr.  Charles  H.  Hughes  {American  Journal  of  Insanity,  1875)  alludes 
to  the  peculiar  mental  state  of  dualitj^  which  sometimes  follows  head  in- 
juries— a  condition  in  which  one  hemisphere  apparently  fills  a  vicarious 
office.  He  refers  to  a  case  presented  by  Joffe,  and  gives  the  main  points 
of  the  histor}'',  which  is  the  following :  "  He  was  a  married  man,  aged 
fifty-three,  healthy  in  childhood  and  youth,  in  manhood  had  headache 
and  giddiness ;  was  a  soldier  fourteen  years ;  in  encounters  with  smug- 
glers received  several  cuts  in  the  head.  His  temper  was  irascible ;  he 
was  fond  of  drink,  had  hemorrhoids  and  constipation  for  ten  years. 
Disposition  serious.  His  memory  failing,  he  became  unfit  for  service 
and  was  discharged  in  1861.  His  pecuniary  circumstances  caused  him 
great  anxiety,  and  in  the  same  year  (1861)  he  exhibited  unmistakable 
signs  of  mental  disturbance.  He  continually  employed  the  expression 
'  we ' — '  we  win  go,'  ^  we  wiU  run,'  '  we  wiU  do  it,'  etc.  The  '  other '  man 
pulled  his  ear,  plucked  his  arm,  etc.  His  left  arm  had  spasmodic  twiteh- 
ings.  He  invited  himself  to  dine  with  his  sister,  saying  that  the  '  other 
man '  compelled  him  to  be  her  guest.  While  eating  he  said,  '■  I  have 
eaten  enough,  but  the  other  has  not.'  After  the  meal  he  ran  out  of  the 
house ;  when  arrested  said  the  '  other '  was  to  blame — he  was  doing  what 
he  could  to  make  him  stop.  Tried  to  murder  a  child,  assigning  a  similar 
cause  for  the  attempt.  He  rolled  into  the  gutter,  thinking  he  was  wrest- 
ling with  '  the  other,'  and  finally  attempted  to  commit  suicide,  imagining 
he  was  killing  '  the  other.'  This  brought  him  to  the  hospital.  The  con- 
formation of  head  was  normal,  pupils  contracted  unequally,  reaction  to 
light  in  both  limited.  Hearing  normal,  but  saw  small  animals,  insects, 
etc.,  with  left  eye,  and  vision  dim  in  right  eye.  Tearing  pains  in  left  ear 
and  side  of  face.  Physiognomy  anxious  and  expressive  of  suffering. 
Skin  dr}^,  and  temperature  and  sensibility  of  body  natural.  Pulse  sev- 
enty-eight. Reflex  movement  to  tickling  soles  of  feet  prompt.  No 
digestive  trouble. 

"  The  '  other '  person  was  in  his  left  side  under  his  skin.     He  called 

himself  the  right  D (D was  his  name) ;  the  left  D was  a 

rascal  and  caused  aU  his  misfortunes.  He  sometimes  presented  the 
picture  of  anxiety,  dripping  with  sweat,  and  holding  fast  his  shirt  with 
both  hands,  in  order,  as  he  said,  to  make  himself  stop.  He  had  violent 
impulses  to  motion,  lasting  an  hour  or  two,  occurring  several  times  in 
the  com^se  of  six  weeks,  and  which  were  probably  epileptic  or  epileptoid 
seizures.  After  conversing  some  time,  long  enough  probably  to  weary 
and  morbidly  disturb  the  sound  hemisphere,  his  ideas  grew  confused, 
and  it  was  impossible  to  gather  any  sense  from  what  he  said. 

"  He  died  of  dysentery,  and  during  the  progress  of  the  disease  had 
no  apparent  delusions.  '  The  autopsy  revealed  a  thickened  dura  mater. 
On  the  left  side  of  the  falx  there  was  a  lamina  of  bone  half  an  inch  long 
and  a  quarter  of  an  inch  broad.     The  membranes  along  the  course  of 


IXSAXITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  107 

the  vessels  were  opaque,  infiltrated  with  seriiin,  their  veins  quite  full. 
Convolutions  of  the  anterior  lobes,  especially  the  left  lobe,  very  mu(;h 
thinned  on  the  convexity — left  anterior  lobe  half  an  inch  shorter  than  the 
right.  Anterior  half  of  ventritde  of  this  side  was  adherent  and  liard. 
Optic  thalamus  and  corpus  striatum  atrophied — especially  the  lattci-. 
Brain  moist,  aiupmic,  tough.  Epeudyma  of  the  lateral  ventricles  tliiclv- 
ened  and  granulated,  corresponding  to  the  thinned  convolutions  of  tlu^ 
anterior  lobe.  The  cortex  was  thinned,  and  the  adjacent  medulla  was 
indurated  to  the  touch.' " 

The  loss  of  memory  that  may  occur  after  cerebral  injury  may  or  may 
not  be  connected  with  other  symptoms  of  insanity.  When  we  consider 
that  the  lesion  may  vary  from  a  simple  ischemic  one,  due  to  concussion, 
to  a  minute  and  general  disorganization  of  the  brain  substance,  it  is 
reasonable  to  expect  widety  varying  symptoms.  Bell  arranges  the  de- 
fects that  may  follow  a  cerebral  traumatism  as :  "1.  An  instantaneous 
unconsciousness,  that  is  to  say,  loss  of  recognition  of  one's  individuality, 
followed  by  giddiness,  stupidity,  foolish  talking,  etc.,  which  may  pass  off 
sooner  or  later,  but  still  is  in  immediate  relation  to  the  accident,  and 
gradually  disappears.  2.  A  set  of  phenomena  very  various  in  nature 
and  amount,  beginning  a  few  hours  after,  and  depending  on  structural 
and  inflammatory  changes  in  the  cranial  contents,  feverishness,  delirium, 
di'eams,  etc.,  passing  off  into  fever  or  lapsing  into  coma,  from  compres- 
sion :  if  from  hemiplegia  these  may  be  very  rapid ;  if  from  meningitis 
they  may  be  slower,  and  the  development  is  to  be  counted  by  days  and 
weeks.  3.  A  state  of  phenomena  of  a  much  lighter  and  more  dangerous 
character,  beginning  with  structm-al  changes  in  the  cranial  contents  in 
the  direction  of  atrophy  or  softening,  where  you  may  have  delusions, 
loss  of  memory,  paralysis,  and  dementia."  He  alludes  to  numerous  cases 
where,  in  addition  to  the  above,  the  patient  had  forgotten  entirely,  not 
only  the  circumstances  connected  with  the  accident,  but ''  a  certain  length 
of  time,  varying  in  different  cases  from  minutes  up  to  hours  and  even 
days,  with  all  its  actions,  pains,  and  pleasures,  before  the  accident  hap- 
pened." A  recognition  of  this  condition  of  affairs  is  of  immense  impor- 
tance in  those  cases  where  testimony  is  given  concerning  the  details  of 
the  accident,  and  a  strong  point  is  very  often  made  (and  sometimes  un- 
justly admitted  in  court)  that  the  story  of  the  patient  is  false,  because  he 
cannot  remember  the  manner  in  which  he  was  injiu'ed,  or  his  beha\dor  at 
the  time ;  and  it  may  perhaps  be  insisted  that  he  was  drunk,  when  such 
was  not  the  case. 

After  surgical  operations  of  various  kinds  the  subject  may  suddenly 
develop  a  coufusional  insanit^y,  which  is  short-lived,  and  violent  while  it 
exists.  Whether  due  to  shock,  loss  of  blood,  or  reaction  following  men- 
tal apprehension,  it  is  difficult  to  say.  It  would  appear  that  g^Tiecological 
operations  in  particular  are  those  which  are  most  frequentlj^  followed  by 
the  lighting  up  of  mental  symptoms. 


XIII.   POST-FEBRILE  INSANITIES. 

The  fevers  and  other  diseases  in  which  exliaustion  has  been  great,  or 
where  pathological  destruction  or  injury  has  invaded  the  brain,  may  be 
followed  by  insanities  which  rather  suddenly  make  their  appearance, 


108  ^   SYSTJiAl  OF  LEGAL  MEDICLXE. 

either  at  the  tiu'ning-point  in  the  particular  affection  or  dm-ing  conva- 
lescence. There  is  no  regular  expression  of  symjjtoms,  and  illusions, 
liallucinations,  and  delusions,  which  are  generally  unsystematized,  ai-e 
irregularly  expressed  and  are  varied.  Sometimes  the  condition,  by  rea- 
son of  its  incoherence,  is  confused  mth  delirium,  but  unlike  the  latter  is 
inconstant,  and  seems  most  pronounced  in  the  night,  the  patient  being 
fau'ly  in  ]30Ssession  of  his  faculties  during  the  daytime. 

The  M^riter  has  seen  several  cases  of  insanity  after  typhoid  fever  in 
which  the  sjTnptoms  appeared  one  or  two  weeks  after  the  subsidence  of 
the  symptoms  of  the  fever  itself.  In  one  of  these  eases  there  was  wild 
incoherence,  a  rise  of  temperature,  and  refusal  of  food.  A  few  of  the 
cases  become  chronic  or  run  into  dementia,  but  as  a  rule  they  recover 
gi'adually,  and  sometimes  suddenly. 

Xn\    DE3IEXTLA.. 

This  degeneration,  which  when  it  occui's  always  implies  the  beginning 
of  the  vital  end,  may  be  the  result  of  a  continued  simple  (acquired)  form 
of  insanity,  such  as  melanchoha  or  mania,  when  it  is  known  as  secondary 
consecutive  dementia  ;  a  disease  by  itself,  when  it  is  known  as  jJi'iinary  de- 
mentia, paretic  dementia,  and  senile  dementia;  or  a  result  of  destriiction 
incident  to  such  forms  of  coarse  brain  disease  as  hemorrhage,  embolism, 
or  thrombosis. 

All  forms  of  dementia  depend  primarily  upon  the  loss  of  stored-up 
impressions  •  in  other  words,  an  actual  deprivation :  in  this  respect  de- 
mentia differs  from  amentia,  where  no  develoj)ment  has  taken  place.  Its 
extent  depends  upon  the  richness  and  variety  of  stored-up  concepts,  and 
its  progi-ess  upon  the  acquii'ed  degree  of  automatism  and  the  habitual 
regulation  of  concept  stimulation  and  coordination.  Memor}^  is  impaii'ed 
proportionately  with  the  degree  of  enfeeblement,  and  the  involution, 
which  keeps  pace  T^ith  the  advance  of  the  disease,  implies,  fii'st,  a  loss  of 
memory  of  substantives,  a  blotting  out  of  recent  impressions,  and  a  re- 
tention for  a  time  of  those  acquii'ed  before  the  destructive  eifects  of  dis- 
ease had  begun  to  extensively  make  themselves  felt. 

In  comparatively  recent  cases  old  concepts  are  recognized,  expressed, 
and  acted  upon,  while  new  percepts  make  fugacious  impressions  or  none 
at  all.  The  business  man  will  automatically  follow  out  the  routine  work 
of  years,  while  new  creations  are  impossible  and  other  forms  of  capacity 
may  be  lost.  An  isolated  instance  of  ability  and  shrewdness  T\-ill  be 
urged  as  an  index  of  the  mental  health  of  the  alleged  lunatic,  when  he 
occasionally  correctly  perfoi'ms  some  long-learned  and  frequently  prac- 
ticed act.  Ultimately  everything  goes,  and  the  mind  becomes  a  blank, 
and  the  dement  is  physically  and  mentally  slow  and  inactive.  He  later 
becomes  little  more  than  a  child,  "^-ith  aU  of  its  weaknesses  and  silliness 
and  irritability.  He  is  occasionally  petulant,  and  sometimes  ^dolent  in 
a  weak  way.  W^ien  the  disorganization  has  sufficiently  advanced  the 
patient  sinks  into  a  vegetative  state,  disregarding  the  ordinary  decencies 
of  life,  urinating  or  defecating  in  his  clothes,  or  masturbating  publicly. 
Tlie  posture  he  assumes  is  usually  one  of  relaxation,  or  in  old  cases  actual 
rigidity  due  to  his  maintained  posture.  He  sits  bent  forward,  his  eyes 
fixed  upon  -s'acancy,  or  they  are  a^'eited,  whUe  the  saliva  drools  from  the 
corners  of  his  mouth  in  a  e:lah-v  stream. 


INSANITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  109 


XV.    SENILE   DEi^IENTIA. 

This  term  has  been  appUed  to  a  variety  of  primary  dementia  occur- 
ring: in  aged  people,  the  word  primary  being  used  to  denote  an  origiual 
condition,  and  not  a  disease  wliich  is  a  seqnence  of  other  inorbid  states. 
It  is  rare  before  sixty,  and  when  it  occurs  hiter  in  life  is  difficidt  to  dis- 
tinguish from  the  natural  decay  of  old  age.  Its  early  symptoms  may  be 
depression  or  exhilaration,  amounting  on  the  one  hand  to  simple  melan- 
cholia, or  on  the  other  to  a  light  grade  of  mania ;  or  there  may  be  nothing 
else  but  an  apparent  increasing  mental  feebleness,  with  loss  of  memory, 
irritability,  and  superficial  delusions  of  suspicion  and  persecution,  and 
he  is  apt  to  believe  that  he  has  been  robbed.  He  conceals  and  hides  his 
papers,  or  puts  useless  objects  he  may  have  hoarded  in  out-of-the-way 
places.  He  may  tie  a  stone  or  cigar-end  in  his  pocket-handkerchief,  or 
secrete  bits  of  thread,  buttons,  etc.,  in  his  different  pockets.  He  is  wake- 
ful and  is  inclined  to  wander  from  room  to  room  during  the  night,  or 
away  from  home,  and,  like  a  young  child,  is  afterward  unable  to  give 
much  account  of  himself.  His  unconcealed  immoralities  are  noticeable, 
and  he  indulges  in  orgies,  and  may  hire  the  entire  personnel  of  a  house 
of  prostitution  for  a  sexual  debauch.  He  makes  indecent  advances  to 
little  girls  or  boys,  exposing  his  genitals  in  the  streets.  In  a  more  ad- 
vanced form  he  urinates  publicly  and  ostentatiously ;  is  careless  of  his 
dress,  leaving  his  trousers  unbuttoned.  He  is  vacillating,  and  apt  to 
squander  his  money  recklessly ;  enters  into  absurd  schemes,  or  gives  his 
property  away  to  persons  who  have  no  claim  upon  him  whatever.  He  is 
the  prey  of  sharpers  or  confidence  men.  His  erotic  excitement  "\vill  often 
subject  him  to  the  arts  of  designing  women,  who  for  one  pui'pose  or 
another  seek  to  gain  control  of  his  property.  Such  old  men  are  apt  to 
marry  women  many  years  their  juniors,  and  to  resent  the  interference 
of  their  children,  upon  whom  tl}ey  turn,  often  disinheriting  tliem.  In  fact 
they  are  inconsiderate  and  without  affection.  Sometimes  their  sexual 
weakness  leads  to  the  wi'iting  of  love-sick  letters  to  numerous  women  at 
the  same  time,  the  wi'iter  being  unconscious  of  the  ludicrous  position  in 
which  he  has  placed  himself.  The  mind  toward  the  end  becomes  nu^re 
and  more  weakened,  and  the  patient  sinks  into  an  exhausted  condition 
and  finally  dies. 

XVT,    PRBIARY  DEMENTIA   (OF  YOUTH). 

Primary  dementia,  so  called,  is  a  somewhat  misleading  synonym  for 
stuporous  melancholia  ending  in  dementia.  It  has  Iw  some  been  applied 
to  the  dementia  of  adolescent  insanity.  Spitzka  classes  this  dementia 
and  W\^t  of  senility  together,  very  properly  believing  them  both  to  be 
involutional  degenerations — in  which  conclusion  I  am  disposed  to  agree. 
Acute  dementia  has  been  spoken  of,  and  has  been  used  to  designate  that 
form  of  rapidly  developing  mental  weakness  so  common  sometimes  in 
youth.  These  patients,  as  a  rule,  manifest  a  depression,  with  introspec- 
tion and  silliness.  The  depression  deepens  into  a  state  of  hebetude,  with 
silence  which  is  so  pronounced  that  it  is  often  impossible  to  draw  forth 
any  response.  The  young  subject  nuiy  be  indifferent  to  his  surroundings 
and  to  all  the  demands  of  nature.     Occasional!}'  such  dementia  is  pre- 


110  A   SYSTEM  OF  LEGAL  MEDICLNE. 

ceded  by  an  insanity  which  consists  of  elation,  inordinate  conceit  and 
vanity,  rehgions  doubts,  and  sexual  aberration  manifested  by  masturba- 
tion or  onanistic  hypoehondi-iasis.  A  degree  of  forgetfulness  and  confu- 
sion follows  this.     There  are  not  necessarily  hallucinations  or  delusions. 


x\t:i.  paretic  dementia. 
{General  Paresis;  General  Paralysis;  Dementia  Paralytic.) 

This  important  disease  is  of  a  progressive  natui'e,  runs  a  compara- 
tively rapid  course,  and  is  symptomatized  by  important  departures  from 
the  normal  psychical  and  physical  condition.  True  paretic  dementia  is 
a  disease  of  adult  life,  though  exceptional  cases  have  been  recognized  in 
childhood  as  a  result  of  congenital  syphilis.  Such  an  one  is  that  observed 
by  Clouston. 

Paretic  dementia  runs  a  course  which  is  comparatively  characteristic, 
but  two  forms  of  mental  disease  closely  resembhng  it.  One  is  "  alco- 
hoHc  general  paresis,"  which  is  an  irregidar  form  of  chronic  alcoholism  j 
the  other  "  pseudo-general  paresis,"  which  is  due  to  active  coarse  cerebro- 
spinal destruction,  due  to  syphditic  infiltration,  and  the  spinal  symptoms 
are  as  important  as  the  cerebral.  Some  writers  have  sought  to  make  close 
differentiation  of  forms  which  have  a  syphilitic  origin  from  others  with 
no  such  basis,  but  I  believe  this  to  be  a  difficult  matter. 

Paretic  dementia  is  a  disease  in  which  conspicuous  mental  and  phys- 
ical symptoms  are  presented.  Beginning  with  slight  alterations  in  man- 
ner, which  are  often  disregarded  or  mistaken,  and  with  very  subtle  phj'sical 
changes,  the  affection  very  rapidly  advances,  so  that  before  many  months 
there  can  be  no  doubt  as  to  its  nature.  It  nearly  always  follows  dissi- 
pation, remote  syphilis,  or  high  living,  and  is  modified  by  alcoholism, 
though  undoubtedly  in  a  few  patients  no  such,  causes  exist,  and  irregu- 
lar mental  overwork  is  sufficient  to  account  for  its  genesis.  In  America, 
especially,  we  find  that  the  unreasonable  haste  to  accumulate  riches,  and 
the  overvaulting  ambition  to  keep  abreast  with  the  more  successful,  have 
had  much  to  do  with  the  development  not  only  of  nervous  diseases  in 
general,  but  paretic  dementia  in  particular. 

The  appearance  of  symptoms  is  somewhat  irregular.  In  a  large  num- 
ber of  cases  we  find  a  preliminary  depression  which  has  a  hypochondri- 
acal tinge,  and  this  is  common  where  there  is  early  alcoholism,  and  is  as- 
sociated with  hopelessness  and  simple  melanchoha.  In  others  the  early 
active  symptoms  are  expansive,  and  in  a  third  class  of  cases  shif  tlessness 
and  forgetfulness  betoken  a  departure  from  the  normal  mental  health. 
Sometimes  a  convulsive  attack  will  be  the  first  thing  to  impress  the  friends 
of  the  patient  with  his  real  state.  The  usual  mental  change,  after  care- 
lessness in  appearance  and  habits,  may  be  a  boastful  vanity  which  ren- 
ders the  individual  ridiculous,  when  mere  lying  is  followed  by  the  wildest 
Munchausen  braggadocio.  He  will  perhaps  tell  you  that  he  has  horses 
which  are  faster  than  any  in  the  world ;  that  his  diamonds  exceed  in  value 
the  crown  jewels  of  all  the  European  courts ;  or  that  he  has  made  impos- 
sible explorations  and  voyages.  Later  on  he  grows  more  expansive  and 
reckless  in  his  statements.  One  man  told  me  that  he  had  hired  Patti, 
Nilson,  and  aU  the  great  prima  donue,  and  had  built  an  opera-house  ten 


IXSAXITY  IN  ITS  MEDICO-LEGAL   BKAIIIXGS.  HI 

miles  long;  another  that  he  could  speak  all  the  known  hmguafres,  in- 
cluding Arabic,  Sanskrit,  and  Hebrew,  although  he  was  a  printer  witli 
scarcely  any  education  of  which  to  speak.  Many  paretics  believe  them- 
selves possessed  of  extraordinary  physical  force,  and  avow  their  power 
to  lift  the  heaviest  weights  and  perform  the  most  extraordinary  feats. 
The  grand  delusions  of  some  take  the  form  of  sexual  capacity,  and  it 
is  not  rare;  to  find  them  boasting  of  powers  that  excelhid  those  be- 
longing to  any  of  the  personages  of  the  Old  Testament  who  possessed 
innumerable  concul)ines.  With  tliis  there  is  foolish  extravagance  and 
the  purchase  of  useless  things.  One  num  will  conti-a(;t  for  property  for 
whic^h  he  cannot  pay,  or  Ijuy  numljcrless  pictures  for  which  he  has  no 
use,  lie  will  order  large  quantities  of  jewelry  or  precious  stones.  He 
resents  interference  and  the  counsel  of  friends  with  violence,  and  plunges 
into  the  wildest  excesses.  He  deljaiu-hes  himself  and  consorts  with  pros- 
titutes, and  no  form  of  bestiality  satisfies  his  desires.  At  this  time  it 
will  be  noticed,  perhaps,  that  his  pupils  are  uneqrudly  dilated,  one  being 
larger  than  the  other  (usually  the  right),  or  that  ili&y  are  contracted  to 
the  size  of  pinheads.  His  tongue,  when  protruded,  tremljles  slightly, 
the  tremoi'  being  fine,  and  accompanied  with  sudden  retraction  of  the 
whole  organ  when  the  effort  is  continued  to  keep  it  protruded.  As  the 
disease  advances  the  lips  in  turn  become  tremulous,  and  the  corners  of 
the  moutli  uneven.  The  speech  is  clumsy,  and  there  is  great  difRculty  in 
pronouncing  the  labials  and  lingual  consonants.  The  mental  state  keeps 
pace,  and  the  delusions  are  more  marked — they  are,  however,  occasion- 
ally concealed,  but  this  is  rare.  It  is  c<jmmon  to  find  fits  of  violence 
from  time  to  time,  and  in  these  the  patient  may  be  actually  dangerous. 

Paretic  dementia  is  characterized  by  periods  of  remission,  which  nuiy 
last  several  weeks  or  sometimes  much  longer,  during  which  the  patient 
is  apparently  sane  ;  but  they  never  continue  for  any  great  length  of  time, 
and  the  mental  and  physical  symptoms  reappear  with  great  violence. 
As  the  malady  becomes  estal)lished  there  are  changes  in  the  gait,  which 
is  titubating  and  unsteady.  The  patient's  ocular  condition  may  vary,  the 
pupils  for  a  time  becoming  equal,  and  afterward  unequal  again.  The 
temperature  is  elevated  during  the  disease,  more  particularh^  throughout 
the  late  stages,  and  generally  after  periods  of  excitement  or  convulsions. 
These  convulsions  are  not  confined  to  any  one  stage,  and  they  may  even 
occur  up  to  and  into  the  state  of  established  dementia.  Wlien  they  do 
occur  they  are  a  most  striking  symptom  of  the  nuilady,  and  should  settle 
our  doubts.  The  writer  has  recently  seen  a  patient  whose  early  mental 
disturbance  was  very  irregular,  inasmuch  as  there  was  a  condition  of  ex- 
treme excitement,  violence,  and  unsystematized  delusions  and  halluci- 
nations which  were  expressed.  His  state  for  weeks  was  one  of  al)solute 
incoherence,  and  the  diagnoses  of  acute  mania  and  confusional  insanities 
were  suggested.  The  doubt  of  its  being  paresis  was  temporarily  strength- 
ened by  a  rather  rapid  cessation  of  his  excited  state,  and  by  considerable 
resolution  of  all  his  symptoms  ;  but  quite  recently  a  series  of  convulsions, 
with  slight  facial  henii2)aresis  and  a  return  of  the  old  expressions,  has 
removed  all  doubts. 

Dementia  finally  comes,  and  with  it  an  enfeeblenu^nt  of  all  the  mental 
powers  takes  ])lace.  The  disease  is  remarkably  rapid  in  its  downward 
progress  and  connnonly  ends  fatally  in  three  years ;  yet  there  are  cases 
where  it  has  lasted  eight  or  ten  years,  but  these  are  by  no  means  com- 


112  A   SYSTEM  OF  LEGAL  MEDICINE. 

moil.  Tlie  French  authors  are  disposed  to  consider  the  average  duration 
of  the  affection  to  be  less  than  two  years,  and  some  EiigUsh  writei-s  fix 
it  at  twenty-two  months.  The  duration  of  the  remissions  is  extremely 
variable.  Baillarger  has  reported  nineteen  eases,  in  which  the  period  of 
remission  varied  from  one  month  to  two  years.  Legrand  du  Saiille 
has  presented  six  cases,  in  which  it  varied  from  ten  months  to  two  j^ears. 
Dagonet  believes  that  dnriiig  the  remission  there  is  a  state  of  mental 
feebleness  quite  incompatible  with  perfect  responsibihty.  I  have  known 
of  one  case  where  an  apparent  remission  lasted  for  several  years,  bnt 
every  indulgence  in  liquor,  even  to  the  extent  of  one  or  two  onnces, 
immediately  put  the  patient  back  for  a  month  or  two  into  his  mental 
slough. 

The  early  stages  of  paretic  dementia  are  sometimes  likely  to  be  the 
subject  of  legal  inquiry.  In  the  beginning  of  the  disease  the  individual's 
extravagant  plans  are  apt  to  be  looked  upon  by  laymen  as  simply  evi- 
dences of  great  business  tact  and  energy,  and  sympathetic  juries  do  not 
take  the  trouble  to  ascertain  whether  the  expenditures  are  in  keeping 
with  the  means  of  the  individual.  So,  too,  during  the  apparent  lucid 
intervals,  legal  steps  may  be  takeu  which  are  not  warranted  by  the 
histoiy  of  the  disease.  The  existence  and  manifestation  of  the  irregular 
symptoms  of  paretic  dementia  continue,  the  physical  weakness  advancing. 
Simple  lowering  of  muscular  tone  and  incoordination  deepen  into  flatness 
of  the  face  and  a  loss  of  expression.  Local  paralyses,  especially  of  the 
face,  actual  hemiplegia,  or  complete  loss  of  power  supervenes,  and  the 
patient  dies  of  exliaustion.     Pulmonary  tuberculosis  is  not  uncommon. 

The  emotional  state  from  the  first  is  disturbed,  and  \h.e  shedding  of 
tears  must  not  necessarily  be  looked  upon  as  an  index  of  feeling,  but 
rather  as  a  result  of  relaxation  due  to  defective  innervation.  The  paretic 
often  cries  without  corresponding  stimulation.  Later  he  grows  very  ir- 
ritable and  even  violent,  is  noisy,  salacious,  extravagant  in  his  gestures ; 
or  he  may  be  amiabihty  itself,  making  presents  and  wishing  all  to  enjoy 
his  success.  With  this  phase  of  feeling  there  is  a  sort  of  vanity  which 
leads,  as  was  the  case  in  one  of  my  patients,  to  frequent  visits  to  photog- 
raphers and  the  soliciting  of  newspaper  puffs.  Tow^ard  the  end  this  all 
changes,  and  actual  indifference  and  mental  and  physical  inaction  reflect 
the  estabhshmeut  of  the  final  mental  decay. 


Part  II. — The  Influence  op  Mental  Aberration  upon  the  Capac- 
ity OF  the  Individual. 

The  attitude  of  the  law  in  regard  to  insanity,  as  wiU  be  subsequently 
shown,  is  radically  different  from  that  of  medicine.  The  stern  require- 
ments demanded  for  the  protection  of  the  individual  and  the  community 
have  necessitated  the  divorcement  of  sentiment  from  science,  and  the 
drawing  of  lines  which  sometimes,  perhaps,  seem  unnecessarily  narrow ; 
but  the  great  result,  after  all,  adduces  to  the  good  of  the  nuiiiy.  Pos- 
silily  in  time,  when  psychiatry  has  become  more  definite  in  its  teachings, 
and  there  is  less  uncertainty  regarding  the  significance  of  insane  mani- 
festations and  their  course  and  termination,  we  may  expect  still  fur- 


INSANITY  IN  ITS  MEDICO-LEGAL   IlEAEINGS.  113 

ther  advances  in  the  acceptation  and  application  of  our  exact  find- 
ing's, and  g-reatev  liberality  upon  tlie  part  of  the  courts.  The  law  often 
looks  askance  at  the  term  *'  insanity  "  as  used  by  the  doctor,  and  prefers 
others  of  its  own  adoption,  such  as  tmsoiiiHhirss  of  mind,  or  noa  compos 
mentis,  etc. 

Unsoundness  of  mind  is  used  in  the  most  varied  ways  to  express  con- 
ditions which  incapacitate.  By  the  older  Englisli  jurists,  idiocy,  amen- 
tia, partial  lunacy,  furor,  monomania,  and  a  number  of  other  inexact 
appellations  were  supposed  to  constitute  unsound  mind.  Coke  discarded 
the  term  "lunatic,"  which,  after  all,  implies  a  mental  condition  of  the 
individual  which  is  influenced  by  the  changes  of  the  moon.  To-day 
many  hiwyers  are  inclined  to  look  upon  "unsoundness  of  mind"  as  a 
weak  state  which  is  not  absolute  insanity.* 

The  term  non  compos  nioifls,  however,  is  that  in  con^'entional  use,  and 
if  this  exists,  and  is  determined  by  inquisition,  it  usually  settles  the  mat- 
ter of  incapacity  in  the  eyes  of  the  law,  the  fact  of  the  incarceration  in 
an  asylum  on  proper  affidavits  of  physicians  or  other  persons  not  inter- 
fering with  the  civil  rights  of  the  individual. 

The  law  recognizes  what  are  known  as  lucid  intervals,  believing  that 
^'no  lunatic  is  wholly  without  reason,"  and  satisfying  itself  that  though 
his  conduct  may  perliaps  be  scandalous,  and  most  of  his  actions  ma}'  be 
irrational,  he  may  still  in  some  things  be  clear  enough  to  intelligently 
and  properly  discharge  the  particular  act  which  forms  the  subject  of 
-doubt.t 

How  fully  the  opinion  of  expert  witnesses  is  accepted,  depends  upon 
the  intelligence  of  judges  and  juries,  who  are  sometimes  disposed  to  cling 
to  their  preconceived  ideas  of  what  constitutes  insanity,  and  to  ignore 
the  teachings  of  psychiatry  and  the  evidence  itself.  It  is  to  be  regretted 
that  what  is  sometimes  accepted  as  an  apparently  normal  display  of  in- 
telligence is,  after  all,  either  a  sudden  flash  in  the  intellectual  pan  or 
£i  misleading  expression  which  only  the  student  of  mental  disease  can 
perfectly  understand,  and  not  always  describe.  "  A  lucid  interval,  in  law, 
means  a  suspension  of  the  active  manifestations  of  mental  disorders.  .  .  . 
It  only  means  restoration  to  the  degree  of  enal)ling  the  party  to  judge 
souudl}'  of  the  act."|  (Ordronaux.)  This  disposition  to  give  value  to  iso- 
lated acts  of  insane  people  has  led  to  the  use  of  the  term  partial  Insanlti/. 

*  JVdUis  vs.  LuJiring,  134  Iiid.  447.  Action  to  contest  the  will  of  Catharine  Wallis. 
Unsoundness  of  mind  and  undne  influence  alleged.  The  testimony  showed  that  the 
■deceased  had  been  of  unsound  mind  for  some  years  before  her  death,  altliou<j:h  none 
of  the  witnesses  regarded  her  as  insane.  No  experts  were  called,  but  her  family  phy- 
sician testified  that  in  liis  opinion  "  she  was  not  ftdly  sound  in  mind  or  body  for  sev- 
eral years  before  she  died,"  although  he  did  not  consider  her  insane  or  crazy.  The 
Trial  Court  refused  to  charge  the  jury  that  "unsoundness  of  mind,  in  law,  means  the 
same  thiug  as  insanity."  The  jury  found  for  the  contestants,  and  on  appeal  to  the 
Supreme  Coin-t  tlio  judgment  was  affii'med. 

t  Matter  of  jMacphorson,  1  Couuoly,  '223.  Mrs.  Sara  J.  Macpherson,  the  testatrix, 
was  in  ill  health  and  very  excitable  for  some  time  jirior  to  her  death,  and  exhibited 
■considerable  antipathy  to  her  relatives.  "  These  s^^nptoms  were  chronic  for  some  time, 
hut  at  periods  sJic  ircts  in  fiiU  pos.^cxsio)!  of  her  fdcuUies."  The  will  was  drawn  in  accord- 
ance with  verbal  instructions,  which  were  afterward  substantiated  by  a  note  of  in- 
struction. At  the  time  of  its  execution  she  conversed  rationally  on  the  matters  con- 
nected with  the  will.     Probate  allowed. 

t  HaU  vs.  Warren,  9  Ves.  605;  Boiid  vs.  Ehy,  8  Watts,  GG ;  Gombanlt  vs.  rub. 
Adm.,  4  Bradf.  22G. 


114,  A   SYSTEM  OF  LEGAL  MEDLCINE. 

It  is  no  more  possible,  in  my  opinion,  for  a  partial  disease  of  the  mind 
to  exist  than  a  partial  variola  or  a  partial  phthisis.  It  is  true  that  cer- 
tain insanities  have  limited  forms  of  expression,  bnt  I  have  never  seen 
a  case,  even  of  paranoia  or  some  of  its  allied  psychoses,  or  ''moral  im- 
becility," where  sooner  or  later  there  were  not  more  or  less  decided  in- 
dications of  general  and  j)rofonnd  inteUectnal  disturbance.  It  is  at  best 
a  difficult  thing  sometimes  for  any  one,  no  matter  how  competent  and 
experienced  he  may  be,  to  say  definitely  how  much  the  mind  has  escaped 
general  disorder,  or,  on  the  other  hand,  how  potent  is  the  exercise  of 
reason,  judgment,  and  volition  in  insane  persons  whose  disease  is  imper- 
fectly or  not  at  all  recognized  by  the  world  at  large. 

Sir  John  NicoU's  view  of  lucid  intervals  has  the  ring  of  common 
sense  :  "  In  cases  of  permanent,  progressive  insanity  the  proof  of  a  lucid 
interval  is  a  matter  of  extreme  difficulty,  as  the  court  has  often  had  oc- 
casion to  observe ;  and  for  this,  among  other  reasons,  namely,  that  the 
patient  so  affected  is  not  unfrequently  rational  to  aU  outward  appearances, 
mthout  any  real  abatement  of  his  malady ;  so  that,  in  truth  and  sub- 
stance, he  is  just  as  insane  in  his  apparently  rational  intervals  as  he  is 
in  his  -visible  raving  fits."     {Brogden  vs.  Broivn^  2  Add.  445.) 

The  law  imposes  responsibility  upon  the  insane  person  whose  acts 
performed  during  the  lucid  intervals  are  the  subject  of  question ;  but 
the  burden  of  proof  is  upon  those  who  seek  to  excuse  or  negative  such 
acts.  Tlie  fact  of  his  being  under  restraint  in  aii  asylum  at  the  time  the 
act  was  committed  is  no  excuse,  for  it  is  presumed  that  he  may  have  a 
lucid  interval  there  as  well  as  elsewhere.  (5  Dow,  Pr.  C.  236.)  This  atti- 
tude of  the  law  is  to  be  borne  in  mind  by  those  persons  wlio  obtain  the 
signatures  of  patients  to  deeds,  notes,  checks,  or  other  instruments,  either 
before  actual  commission  or  after  incarceration.  As  has  been  before  said^ 
nothing  fixes  the  status  of  the  insane  person  but  a  regular  inquisition,* 

General  Questions  Relative  to  Capacity. 

The  ci%Tl  issues  that  occur  where  the  question  of  responsibility  arises 
are  those  which  relate  to  the  individual  and  his  ability  to  care  for  himself 
and  Ms  property,  to  understandingly  enter  into  contracts,  and  to  dispose 
of  his  possessions.  These  are  numerous  and  constantly  occup3dng  the 
attention  of  courts  of  law.  It  is  the  duty  of  the  medical  witness  to  care- 
full}'  examine  the  person  whose  sanity  is  questioned,  and  to  pass  judg- 
ment upon  his  Avritten  and  other  productions ;  to  obtain  a  history  of  his- 
conduct,  and  to  form  an  intelligent  opinion  therefrom.  It  becomes  nec- 
essary to  discover,  if  possible,  the  existence  of  a  delusion  which  will  in- 
validate the  i^articular  act,  as  being  a  result  of  an  insane  exercise  of  judg- 
ment and  reasoning  power.  The  word  "  insane  "  is  iised  in  contradistinc- 
tion to  the  careless  or  conscious  error  which  any  normal  individual  may 
make,  and  which  does  not  necessarily  indicate  impairment  of  responsibil- 
ity. If  a  business  arrangement  is  entered  into  b.y  a  person  who  is  non 
compos  mfiutis  and  does  not  realize  what  may  be  the  consequence  of  his 
act,  he  is  entitled  to  the  protection  of  the  law.   We  are  to  determine  just 

*  Shelforcl  on  Lnnac)/,  p.  340;  Rix  vs.  Wliitfenwre,  4  Mete.  545;  Haden  vs.  Uoi/cs, 
9  Pa.  151 ;  Jaclson  vs.  Van  Viisen,  5  Johns.  144;  Stevens  vs.  Van  CJeve,  4  Wash.  C.  C. 
262.     The  author  is  indebted  to  Ordronaux  fox'  many  of  these  citations. 


IXSAXFTY  IX  ITS  M EDICO-LKCAL   BEAIlIXaS.  115 

what  form  of  a-bciTatioii  incapacitates,  altliougli  soinctinies  the  general 
showing"  that  insanity  exists  will  sullice.  Careful  judg'cs  recjuire  tlie 
exaet  estimation  of  mental  (lisc.iso  that  destroys  i-es[)onsil)ility,  and  how 
it  does  so,  recognizing-  the  fact  that  extensive  disorder  may  exist  which 
spares  the  individual  so  far  as  the  ability  to  perform  certain  acts  is  con- 
cerned. Usually  the  conservation  of  the  power  to  know  the  provisions 
^nd  consequences  of  the  particrda,r  act,  and  the  ability  to  exercise  will- 
power, are  sufficient  to  meet  the  demands  of  the  law,  no  matter  how  de- 
ranged the  person  may  otherwise  be.  This  is  shown  in  the  admission 
of  wills  to  probate  which  have  been  made  by  insane  men  who,  so  long  as 
they  were  not  subject  to  undue  influences  or  laboring  under  a  delusion 
touching  the  matter  at' issue,  were  considered  comj^etent. 

The  Gei'man  law  in  regard  to  capacity  differs  but  little  from  that  of 
•our  own  country  in  admitting  that  no  matter  what  the  condition  of  re- 
straint or  general  state  of  a  patient  maj^  be,  the  existence  of  testamentary 
capacity  must  be  specifically  determined  by  his  knowledge  of  the  partic- 
ular act.  In  a  recent  case  which  was  decided  May  7,  1889  [Entscheidnngen 
des  Reich sgerichts  in  Ciiilsachen,  vol.  xxiii.,  p.  140),  it  was  held  that  though 
a  man  had  been  under  the  care  of  a  legally  appointed  guardian,  and  had 
been  declared  insane  in  1885,  the  court,  after  an  inquisition,  considered 
Mm  in  1889  sane  enough  to  make  a  will.  The  contesting  parties  alleged 
that  a  person  under  the  care  of  a  trustee  is  incompetent  to  make  intelli- 
gent disposition  of  his  or  her  property ;  the  will,  however,  was  admitted 
to  probate  by  reason  of  the  assumed  existence  of  a  lucid  interval. 


TESTABIENTARY  CAPACITY. 

It  would  appear,  then,  as  if  the  ability  to  legally  dispose  of  one's  prop- 
erty depended  upon  the  possession  of  but  a  limited  degree  of  intelli- 
gence, for  the  requirements  are  a  knowledge  of  one's  possessions  and  the 
objects  of  one's  bounty.  Erskine's  charge  in  the  case  of  Hurwood  vs. 
Bcu'l-er  was  as  follows  :  "  Tlieii-  lordships  are  of  opinion  that  in  order  to 
<3onstitute  a  sound  disposing  mind  a  testator  must  not  only  be  able  to 
understand  that  he  has  by  his  will  given  the  whole  of  his  property  to 
one  oljject  of  his  regard,  but  he  must  also  have  capacity  to  comprehend 
the  extent  of  his  property  and  the  nature  of  the  claims  of  others  whom 
by  his  will  he  is  excluding  from  all  participation  in  that  property ;  and 
that  the  protection  of  the  law  is  in  no  cases  more  needed  than  it  is  in 
those  where  the  mind  has  been  too  much  enfeebled  to  comprehend  more 
objects  than  one,  and  more  especially  where  that  object  may  be  so  forced 
upon  the  attention  of  the  invalid  as  to  shut  out  all  others  that  might  re- 
quire consideration." 

With  regard  to  the  proof  of  a  disposing  mind  an  English  judge  (Brett) 
said  that  "  it  was  not  sufficient  for  the  testatcn-  to  understand  merely  that 
he  was  making  a  will,  but  they  [the  jury]  had  to  say  whether,  at  the  time 
the  will  was  made,  the  testator  had  sufficient  intelligence  to  understand 
substantially  the  state  of  his  family  and  of  his  affairs,  and  the  disposition 
of  his  propei'ty  as  made  by  the  will ;  and  if  he  had  sufficient  power  of 
mind  to  intend  to  make  such  disposition." 

We  are  to  investigate  the  condition  of  the  testator  at  the  time  he 
makes  his  will,  and  decide  whether  his  disposing  capacity  is  affected  in 


116  A   SYSTEM  OF  LEGAL  MEDICIXE. 

any  way — either  by  the  natural  decay  of  old  age,  b}^  senile  dementia,  or 
by  other  kinds  of  insanity — or  whether  there  exists  a  delusion  which 
prevents  him  from  intelligently  disposing  of  his  holdings. 

Wills  made  in  Extremis. 

Wills  made  in  extremis  usually  have  no  value  in  the  ej-es  of  the  law^ 
and  these,  as  well  as  contracts,  are  often  contested. 

Tardieu,  Lasegue,  and  other  French  wiiters  have  extensively  written 
upon  the  mental  condition  of  the  individual  diu-ing  the  last  moments  of 
life.  They  announce  their  belief  that  either  as  a  result  of  general  disease 
or  insanity  the  brain  is  always  aif ected  just  before  death,  and  intelligence 
obscured  to  some  extent,  so  that  the  capacity  for  will-making  is  at  least 
doubtful.  There  certainly  can  be  no  question  as  to  the  mental  weakness 
that  occurs  when  puhnonar}^  decarbonization  fails,  and  the  brain  is  sup- 
plied  with  vitiated  blood ;  and  there  can  be  no  doubt  that  just  before  death 
there  must  be  a  dissolution  and  incoordination  of  concept  arrangement. 
The  instances  of  hallucinatory  disorders  that  are  gravely  presented  in 
good  faith  by  credulous  people  as  death-bed  utterances  and  prophecies- 
are  numerous  and,  after  all,  significant  indications  of  disorganization. 
It  therefore  cannot  l^e  denied  that  the  last  hours  of  life  are  frequently 
attended  by  mental  obscuration  or  perversion,  even  when  such  does  not 
appear  to  be  the  case  to  outsiders ;  and  a  person  with  some  assistance 
may  be  helped  to  sign  and  apparently  understand  a  will.  Some  diseases, 
when  the  cause  of  death  is  toxemia  or  great  exliaustion,  must  sometimes 
interfere  with  the  clear  exercise  of  judgment.  An  aged  man  whose  will 
was  lately  the  subject  of  contest  died  after  a  week's  illness,  the  nature  of 
which  was  strangulated  hernia  and  peritonitis.  Shortly  before  death  he 
was  made  to  sign  a  wiU,  notwithstanding  the  fact  that  soon  after  he  was 
so  deUrious  that  it  required  the  efforts  of  several  men  to  hold  him  down, 
and  he  presented  the  signs  of  collapse ;  yet  he  was  pronounced  by  the 
consulting  physician  in  his  case  to  be  of  sound  mind. 

For  obvious  reasons  it  is  impossible  to  fix  a  limit  of  time  before  death 
when  a  wiU  should  be  rejected.  Of  course  the  particular  circumstances 
should  be  determined  and  weighed.  In  a  condition  symptomatized  by 
mental  indecision  due  to  weakness,  especially  where  semi-consciousness 
is  present,  the  assertion  that  testamentary  capacity  exists  should  be  re- 
ceived with  some  hesitation ;  and  where  the  person's  condition  is  such 
that  he  has  to  be  supported  and  a  pen  held  in  his  hand — the  aid  not  be- 
ing alone  required  because  of  existing  paralysis — I  think  we  cannot  be 
too  careful  in  sifting  to  the  bottom  the  testimony  that  may  be  admitted.. 

Old  Age  and  Dementia. 

Much  has  been  said  about  the  distinction  between  the  mental  decaj^ 
of  simple  old  age  and  the  appearance  of  senile  dementia,  and  it  is  imi)or- 
tant  to  make  the  distinction  when  we  are  called  upon  to  testify.  Dr. 
Ray  says :  *'  This  form  of  the  disorder,  or  senile  dementia,  is  so  often  the 
subject  of  medico-legal  inquiries,  especially  in  connection  with  wills,  that 
it  deserves  particular  attention.  Senile  dementia,  it  must  be  recollected, 
is  something  more  than  the  mere  loss  of  mental  power  which  results- 


INSANITY  IN  ITS  MEDICO-LEGAL  BEARINGS.  HJ 

from  tlio  luitui'iil  decay  of  the  faculties:  it  is  not  only  fo(!l)le,  but  it  is 
derang'ed.  Were  it  not  so  every  old  man  woidd  labor  under  a  certain 
degree  of  dementia."  ISeuile  dementia,  as  Pritcliard  has  written,  is  not 
the  lot  of  old  persons  universally,  thoug'h  it  is  a  condition  to  which  old 
age  has  a  tendency,  and  to  which  the  last  stage  of  bodily  decay  ap])r(jxi- 
mates.  Extreme  old  age  sometimes  prevents  the  testator  from  knowing 
the  objects  of  his  bounty,  and  from  intelligently  disposing  of  his  estate. 
If  his  mind  is  so  weak,  either  through  disease  or  advanced  j'ears,  that  he 
may  be  tricked  or  swindled ;  if  his  memory  and  perception  are  so  blunted 
as  to  prevent  him  from  knowing  the  extent  or  condition  of  his  property 
or  the  persons  to  whom  he  wishes  to  give  it — then  true  doubts  arise  in  re- 
gard to  his  competency.  Simple  old  age  does  not  necessarily  bring  with 
it  incapacity,  for  there  are  men  who  have  attained  veiy  great  age  without 
any  suspicion  of  mental  unsoundness  arising.  In  the  Watson  Case  an  old 
man  of  eighty-six  was  held  to  be  competent  to  make  a  will,  and  cases  are 
on  record -of  wills  nuide  at  ninety,  or  over,  which  stood.*  The  law  is  that 
''  if  man  in  his  old  age  becomes  a  very  child  again  in  his  understand- 
ing, and  is  become  so  forgetful  that  he  knows  not  his  own  name,  he  is 
then  no  more  fit  to  make  a  testament  than  a  natural  fool,  a  child,  or  a 
lunatic.''     (Browne.) 

Lucy  H.  Eddy  died  in  Railway  in  1879.  She  was  a  daughter  of  the 
late  Thomas  Eddy,  of  New  York,  who  was  distinguished  for  his  public 
spirit  and  philanthropy,  and  inheiited  from  him  his  strong  mental  quali- 
ties and  convictions  .of  duty.  She  left  a  will  dated  January  15, 1875,  and 
a  codicil  dated  September  5,  1876.  This  will  was  contested  in  the  Pre- 
rogative Court  on  the  ground  of  lack  of  testamentary  capacity.  Deceased 
was  eighty-three  j^ears  old  at  the  time  she  executed  the  will,  and  none  of 
the  witnesses  f or -(iontestants  testified  that  deceased  was  of  unsound  mind, 
but  only  averred  to  weakness  of  memory  regarding  recent  occiu-rences, 
which  might  be  expected  in  a  person  of  such  advanced  age ;  and  some 
would  not  even  say  that  she  was  unfit  to  make  a  wiU.  On  the  other 
hand,  it  was  shown  that  she  read  the  classics  and  histories,  and  woidd 
excite  admiration  by  her  able  discussion  of  them ;  that  she  seemed  to  re- 
member old  events ;  she  answered  questions  intelligently ;  knew  what 
she  was  doing ;  that  she  knew  who  her  relations  were ;  that  she  used  an 
old  will  as  the  basis  of  her  will  of  1875,  and  made  all  the  necessary  mem- 
oranda thereon  herself.  Another  point  advanced  by  contestants  was  the 
confidence  reposed  by  deceased  in  her  attorneys,  and  her  indifference  to 
the  fact  that  much  more  money  had  been  expended  on  the  building  of  a 
house  for  her  than  was  at  first  contemplated,  and  it  was  claimed  that 
this  was  evidence  of  the  want  of  that  capacity  requisite  to  the  making 
of  a  will ;  but  it  was  held  that  this  nun-ely  amounted  to  luitural  confidence 
in  capable  business  men.  Held,  also,  that  mere  forgetfuluess  of  recent 
events  is  no  evidence  of  incapacity  to  make  a  wiU.     The  will  was  there- 

*  Bradji  vs.  MvBvidv,  39  N.  J.  Eq.  495.  The  testatrix,  Margaret  Deviiie,  executed 
her  will  February  l!-i,  1876,  at  "which  time  she  was  blind  and  over  eighty  years  of  age. 
In  October,  1S78,  a  commission  in  lunacy  fmmd  that  she  was  of  unsound  mind  and 
had  been  so  inore  than  throe  years  past.  There  was  mneh  evidence  that  the  testati'ix 
was  rational  at  and  about  the  time  of  the  execution  of  the  will,  not  only  as  to  the  de- 
tails of  the  will  but  also  as  to  her  financial  affairs  and  other  matters. 

Tlie  will  was  admitted  to  probate,  and  on  appeal  judgment  affirmed,  the  cotn-t 
holding  that  the  finding  of  the  commission  in  lunacy  was  not  conclusive  as  to  her 
mental  condition  at  the  time  of  the  execution  of  the  will. 


118  A   SYSTEM   OF  LEGAL  MEDICINE. 

fore  admitted  to  probate.  (32  N.  J.  Eq.  701.)  In  other  cases  the  forget- 
fulness  of  recent  events  might  lead  to  the  disregard  of  those  dependent 
upon  the  testator  as  well  as  the  condition  of  the  estate. 


Influence  of  Delusions. 

The  existence  of  delnsions  regarding  the  next  of  kin  or  others  who 
have  a  claim  npon  the  testator,  or  in  regard  to  the  condition  of  the 
property,  or  which  in  any  way  influence  the  judgment  of  the  testator, 
is  usually  sufficient  to  invalidate  the  bequests  that  may  be  made  through 
such  error.  As  has  been  stated,  delusions  of  the  most  absnrd  nature 
may  exist,  but  do  not  negative  the  existence  of  a  disj)osing  mind.  Cock- 
burn  held  the  following  oiDinion  {Banks  vs.  Goodfellow) :  "  No  doubt,  when 
the  fact  that  the  testator  had  been  subject  to  any  insane  delusion  is 
established,  a  will  shoidd  be  regarded  with  great  distrust,  and  every  pre- 
sumption should  in  the  first  instance  be  made  against  it.  When  in- 
sane delusions  have  once  l^een  shown  to  have  existed,  it  may  be  difficult 
to  say  whether  the  mental  disorder  may  not  possibly  have  extended 
beyond  the  particular  form  or  instance  in  which  it  has  manifested  itself. 
It  may  be  equally  difficult  to  say  how  far  the  delusion  may  not  have  in- 
fluenced the  testator  in  the  particidar  disposal  of  his  j)roperty,  and  the 
presumption  against  a  wiU  made  under  such  circumstances  becomes 
additionally  strong  when  the  will  is,  to  use  the  term  of  the  civilian,  an 
insufficient  one — that  is  to  say,  one  in  which  natural  affection  and  the 
claims  of  near  relationship  have  been  disregarded.  But  when,  in  the 
result,  the  jury  are  satisfied  that  the  delusions  have  not  affected  the  gen- 
eral faculties  of  the  mind,  and  can  have  no  eifect  upon  the  t^tH,  we  see 
no  sufficient  reason  whj^  the  testator  should  be  held  to  have  lost  his  right 
to  make  a  will,  or  why  a  "will  made  under  such  circumstances  should  not 
be  upheld." 

The  celebrated  Jumel  Will  Case  was  one  in  which  the  question  of  de- 
lusion arose.  Madame  Jumel  died  some  years  ago,  leaving  a  large  and 
valuable  estate  to  different  religious  and  charitable  institutions,  cutting 
off  her  family.  It  was  shown  that  the  testatrix,  who  was  a  very  old 
woman  when  the  will  was  made,  was  peculiar  and  crotchety,  and  that 
she  labored  under  the  delusion,  among  others,  that  she  was  the  victim 
of  a  plot — that  her  relatives  had  attempted  to  poison  her — and  so  deep- 
seated  was  her  behef  that  she  refused  all  food  imtil  she  procured  it  her- 
self. The  case  was  tried  in  the  Supreme  Coiu-t  of  New  York  in  1866, 
and  the  court  took  the  position  that  if  she  was  insane  because  of  these 
delusions,  she  was  incompetent  to  make  a  wiU. 

The  instances  where  insane  delusions  have  interfered  with  testament- 
ary capacity  are  numerous  and  bear  a  common  relation,  and  the  reader 
is  referred  to  the  comparativelv  recent  decisions  in  the  cases  of  Merrill 
vs.  Rohto7i,  5  Eedfield,  220;  Mi'ller  vs.  White,  5  Redfield,  320;  DicMe  vs. 
Van  Vied;  5  Redfield  284 ;  Leslie  vs.  Leslie,  15  N.  Y.  Digest,  56.  In  all 
of  these  cases  the  existence  of  delusions  was  urged.*     The  existence  of 

*  Also  see  American  Bihle  Soefeti/  vs.  Storcr,  12  N.  Y.  Weekly  Dicjest,  21.3 ;  Kings- 
hury  vs.  Wliifal-er,  32  Louisiana  Annual  Reports,  1055;  Cole  Will  Case,  49  Wiseonsio. 
Reports,  179;  Le  Ban  vs.   Vandcrhilt,  3  Redfield,  384. 


JXS.IMTY   I\   ITS   MhDJCO-LKa.lL    JlK.UiJXdS.  ]  ]  <J 

insane  delusions  of  a  pertinent  cluiraeter  is  sojnetinies  <lisr('<:,'ar(l<'d,  tlie 
law  preferring'  to  l)elieve  that  at  some  time  the  individual  was  able  to 
dispose  intellig-ently.* 

General  Symptoms  of  Alleged  Incapacitating  Insanity. 

The  suits  brought  by  dissatisfied  benefieiaries  to  ainiul  wills  that  have 
been  made  by  persons  who  are  alleg-ed  to  be  insane  disclose  peculiarities 
of  conduct  Avhieh  often  reach  the  dignity  of  mental  disease,  but  more 
often  are  simply  evidences  of  a  pui-ely  eccentric  nature. t  The  drag-net 
which  is  hauled  Ijy  every  available  helper  brings  into  court  the  thousand 
and  one  little  weaknesses,  the  instances  of  moral  delinquency,  the  moods 
and  idiosyncrasies,  which  most  men  possess.  These  are  colored  and  tinged 
by  interested  witnesses,  persons  with  pliable  memories,  or  those  ha\dng 
€nds  in  view  or  unredressed  "WTongs.  It  may  be  the  son  or  daughter 
whose  cupidity  brings  forgetfulness  of  a  father's  kindnesses,  a  discharged 
servant,  or  some  stranger  who  solely  desires  the  notoriety  of  appearing 
in  court. 

Influence  of  Eccentricity. 

Mere  disproportion  in  the  division  of  property,  or  eccentricity,  is  not 
necessarily  evidence  of  testamentary  incapacity ;  and  although  the  law  is 
very  careful  in  regard  to  the  question  of  undue  influence,  great  care 
should  be  taken  to  distinguish  cases  in  which  the  individual  defers  with 
perfect  propriety  to  the  suggestions  of  intelligent  and  lifelong  friends  in- 
stead of  bad  children  who  never  hav-e  shown  any  filial  respect  or  interest 
in  the  testator  until  the  question  of  the  di\dsion  of  property  is  raised. 

*  Ifaiileifs  Executor  vs.  Staples  (65  Vt.  370).  This  was  a  contest  of  the  will  of  Madi- 
son S.  Manley,  by  his  daughter,  Miriam  A.  Staples.  The  will  was  executed  April  24, 
1888,  and  he  died  July  4,  1888.  Maule.y  was  a  miserly  and  ignorant  old  man,  and  was 
infirm  and  almost  helpless.  Some  years  before  his  death  his  wife  procured  a  divorce 
from  him,  with  alimony  amounting  to  over  one  half  of  his  property,  which,  upon  her 
<ieatli,  previous  to  the  execution  of  Mauley's  will,  slie  bequeatlied  to  the  contestant. 
For  some  years  before  his  death  Mauley  had  an  "  insane  delusion  "  couceniiug  his 
wife  and  daughter,  and  accused  them  of  l^eiug  prostitutes  and  of  conspiring  to  poison 
him.  After  the  death  of  his  wife  he  attempted  to  make  a  contract  with  contestant 
to  take  care  of  him  during  his  life,  but  failed.  Afterward,  on  November  14,  1887,  he 
made  a  contract  witli  one  Fisk  for  his  care  during  his  life,  and  by  the  contract  con- 
veyed most  of  his  jiroperty  to  Fisk.  He  lived  with  Fisk  until  his  death,  and  during 
that  time  was  less  eccentric  than  before.  His  will  recited  and  confirmed  the  contract 
witli  Fisk,  and  bequeathed  all  his  proi:)erty  to  Fisk,  except  some  income  whicli  he  be- 
queathed to  two  grandsons,  who  were  sons  of  the  contestant.  The  Probate  Court  sus- 
tained the  will.  Tlie  Supreme  Court  of  Vermont,  affirming  the  judgment,  held  that 
the  fact  that  insanity  existed  for  a  number  of  years,  wliile  strong  evideiice  of  per- 
manency, was  not  conclusive  of  it :  this  was  a  question  of  fact  for  the  jury.  "That 
insanity  continues  is  not  a  presumption  of  law,  .  .  .  but  an  inference  of  fact,  A'arying 
with  the  circumstances  of  the  case."  There  was  no  evidence  that  he  entertained  an 
insane  delusion  concerning  his  daughter  after  he  went  to  live  with  Fisk  and  at  the 
time  he  executed  the  will.  Objection  was  made  at  the  trial  to  Fisk  as  a  Avitness  be- 
cause lie  was  a  party  to  the  contract  mentioned  in  tlie  will.  The  court  held  that  as 
the  contract  was  not  in  issue  Fisk  was  competent  to  testify  to  the  execution  of  tlie 
will. 

t  Prentis  vs.  Bates,  88  Mich.  567;  rehearing  9.T  Mich.  234.  This  case  was  a  con- 
test of  the  will,  dated  July,  1S86,  of  Mrs.  Adnliiu^  King,  who  died  in  Detroit  in  Novem- 
ber, 1886.     There  was  testimony  showing  that  Mrs.  King,  who  was  sixty-seveu  years 


120  ^   SYSTEM  OF  LEGAL  MEDICINE. 

When,  on  the  other  hand,  a  kind  father,  whose  relations  with  his  chil- 
dren are  of  the  pleasantest  kind,  becomes,  during  the  latter  years  of  hfe,, 
morose,  irritable,  and  shows  unwarrantable  dislike  or  neglect,  with  moral 
and  intellectual  weakness,  grave  doubts  arise. 

Eccentricit}^  should  not  be  misunderstood  and  looked  upon  as  disease^ 
nor  should  superstitious  belief,  or  the  striking  exaggeration  of  character 
of  old  age  we  sometimes  find,  which,  however,  are  perfectly  consistent 
with  mental  integrity.  The  belief  in  spiritualism,  or  any  other  ism^ 
wliich,  perhaps,  leads  the  testator  to  leave  a  legacy  to  some  religious 
body,  no  matter  how  irregular,  is  not  necessarily  insanity-,  and  should  not 
be  so  considered. 

In  courts  of  law  it  is  often  contended  that  because  the  individual 
wears  certain  loud  colors  and  ungainly,  conspicuous  dress,  or  because  he 
eats  or  drinks  or  walks  or  sleeps  in  an  unusual  way,  he  is  of  unsound 
mind.  Not  onl}"  lifelong  peculiarities,  but  personal  traits  which  may  be 
the  offspring  of  ignorance  or  vanity  or  even  vulgarity,  may  sometimes 
be  sufficient  in  the  eyes  of  snobbish  or  ungrateful  children  to  stam]> 
their  parent  as  of  unsound  mind. 

In  the  case  of  Hartwell  vs.  2r Master  (4  Redfield,  38)  it  was  shown 
that  the  deceased  executed  his  "wtH  on  September  25,  1880,  and  died 
October  1,  1880,  aged  seventy-two  years,  leaving  no  children.  He  had 
been  in  business  in  New  York  City,  had  taught  school,  preached,  and 
had  some  knowledge  of  electricity.  On  behalf  of  contestants  it  was 
claimed  that  testator  lacked  testamentaiy  capacity,  and  it  was  shown 
that  he  did  not  believe  in  the  doctrine  of  the  "  real  presence  "  or  transub- 
stantiation,  nor  in  the  necessity  of  baptism  in  infancy;  that  he  lived 
alone  and  locked  himself  in  dm-ing  his  last  illness ;  that  he  had  once 
disturbed  a  religious  meeting  by  abusing  the  minister ;  that  he  wished  to 
attend  a  i^ublie  school  as  a  pupil ;  that  when  over  sixty  years  old  he  fell 
in  love  with  a  girl  of  twelve.  It  was  very  properly  held  that  these  things 
alone  were  not  sufficient  to  prove  that  testator  was  insane  or  lacked  tes- 
tamentary capacity. 

The  Influence  of  General  Diseases. 

Bodily  disease  may  result  in  an  insanity  that  may  destroy  the  dis- 
posing powers  of  the  individual.  Such  somatic  insanities  as  that  due  to 
Bright's  disease  are  frequently  referred  to,  but  more  often  great  stress 
is  laid  by  counsel  upon  the  existence  of  the  cerebral  symptoms  of  this 

old  at  the  date  of  the  will,  was  eeeentric,  fickle-minded,  continually  interfering  with 
and  scolding  with  workmen  about  her  house.  It  was  also  shown  that  a  sister  of  Mrs. 
King,  who  died  in  1863,  had  been  insane,  and  had  several  times  from  1840  to  1858 
been  placed  in  retreats.  She  could  not  remember  from  one  day  to  another  when  she 
had  taken  a  bath,  and  frequently  after  ordering  meals  at  a  restaurant  (in  1884)  denied 
that  she  had  ordered  the  food  that  was  brought  to  her.  She  continually  comiilained 
of  aggravated  stomach  trouble,  and  shortly  before  her  death  ate  a  bowl  of  chicken 
broth  which  she  had  kept  in  her  room  for  three  days,  and  which  was  not  fit  to  eat. 
{Sic.)  A  few  days  thereafter  she  died  of  dysenteiy.  A  fjost-mortem  examination 
showed  no  chronic  stomach  disease.  At  one  time  Mrs.  King  was  a  patient  at  a  sani- 
tai-ium.  Dr.  Gallagher,  one  of  the  attendant  physicians,  testified  that  he  took  pills  to 
her ;  she  would  not  take  them — said  they  were  flies'  heads.  He  then  got  a  fly's  head 
and  she  took  it.  The  proliate  of  the  will  was  disallowed,  and  on  appeal  the  Supreme 
Court  reversed  and  ordered  a  new  trial  (88  Mich.  567).  On  rehearing  the  judgment  of 
reversal  was  upheld  except  as  to  costs  (93  Mich.  234). 


IXSAmTY  IX  ITS  MEDICO-LEGAL  BEARINGS.  121 

and  other  diseases,  and  their  effect  upon  tlie  eonduet  of  the  individual. 
Very  often  such  petitioners  are  apt  to  forniuhite  deeidedly  orijiinal  \  iews 
regarding  the  pathoh)gy  of  the  conditions,  and  to  draw  unwarranted 
conclusions  therefrom.  Such  was  the  issue  in  the  Jesse  Hoyt  Will 
Case,  where  great  contention  was  caused  and  much  irrelevant  testimony 
given  regarding  the  morbid  anatomy  of  the  kidneys.  Beyond  the  irri- 
tahility,  stupidity,  aphasia,  and  very  rare  epileptic  conditions,  nothing 
can  be  shown ;  but  when  we  consider  tlie  renal  disease,  with  cardiac 
disease,  as  precursors  of  actual  degeneration  of  the  cerebral  vessels,  it 
has  a  decided  importance.  The  demonstration  of  the  connection  between 
emljolism  or  cardiac  disease  with  cerebral  softening  and  dementia,  of 
syphilis  with  paretic  dementia  or  epilepsy,  is  of  the  greatest  moment. 

The  distrust  of  the  courts  in  considering  sitcIi  matters  is  often  shown. 
Wlien  the  will  of  the  late  Alexander  D.  Fraser,  of  Detroit,  was  contested^ 
the  issue  was  raised  that  his  testamentary  capacity  had  been  destroyed 
by  cancer.  The  will  was  dated  May  17,  1877,  and  the  evidence  showed 
that  the  deceased  was  over  eighty  years  old  and  had  been  suffering  for 
over  twenty  years  from  a  cancer  on  the  nose,  which  ultimately  consumed 
the  flesh  on  one  side  of  his  face  and  also  his  eye,  and  from  which  he 
finally  died  on  August  2, 1877.  Prior  to  the  winter  of  1876  he  had  been 
very  fond  of  societ}^,  had  always  been  neat  in  appearance,  and  kind  and 
considerate  to  the  members  of  his  household;  but  after  that  time  he 
secluded  himself,  became  slovenly,  and  frequently  abused  and  assaulted 
the  members  of  his  household.  He  was  eccentric  in  dress,  and  at  the 
execution  of  the  will  appeared  attired  in  a  night-gown  and  Scotch  cap. 
After  the  execution  of  the  will  (in  May,  1877)  and  up  to  the  time  of  his 
death  he  frequently  had  delusions  and  raved  to  such  an  extent  as  to  dis- 
turb his  neighbors.  On  these  facts  five  physicians  beheved  him  insane. 
On  a  trial  before  the  jury  a  verdict  was  rendered  sustaining  the  will, 
which  verdict  was,  on  appeal  to  the  Supreme  Court,  affirmed.  (-42  Mich- 
igan Reports,  20G.)* 

Cases  Avhicli  are  familiar,  and  Avhere,  as  a  rule,  there  is  sufficient  dis- 
ease of  the  structure  of  the  brain  to  effectually  weaken  the  mental  powers 
to  the  degree  of  irresponsiljility,  may  be  illustrated  by  the  following: 

Sarah  M.  Blakely  executed  her  will  April  7,  1876,  and  it  was  con- 
tested by  her  husband  on  the  ground  of  insanity.  It  appears  that  she 
had  a  stroke  of  apoplexy  in  December,  1875,  and  for  some  time  there- 
after was  subject  to  pai'oxysms  of  grief  and  crying.  In  April  follo'wing' 
she  executed  the  will.  In  the  summer  of  1876  she  had  another  stroke 
of  apoplex}',  and  on  Septemlier  26th  was  sent  to  an  insane  asylum,  where 
she  died  March  10,  1877.  In  February,  1876,  she  ^^Tote  several  clear  and 
coherent  wills.  For  a  long  period  she  had  manifested  a  great  dislike  for 
her  husband  and  entertained  groundless  suspicions  of  him.  She  was 
nervous,  flighty,  excitable  and  hysterical,  discontented  and  unhappy. 
Dr.  Barnett,  who  attended  her,  says  that  after  the  paralytic  stroke  in 
December,  1875,  her  mind  became  enfeebled,  and  that  she  was  suffering 
from  dementia,  and  he  did  not  consider  her  in  a  proper  condition  of 
mind  to  attend  to  business  in  the  spring  of  1876.  Drs.  Hunt  and  Russell 
testified,  as  to  her  condition  before  the  paralytic  stroke,  that  her  conduct 
might  be  the  result  of  nervous  excitement  or  childishness.     Dr.  Kemp- 

*  Also  sec  Ifairs  vs.  Freeman,  3  Redfield,  181. 


122  A   SYSTEM   OF  LEGAL  MEDICINE. 

ster,  superintendent  of  the  asylum  in  which  deceased  Avas  confined,  from 
an  examination  made  in  September,  1876,  believed  her  to  have  been  of 
unsound  mind  in  April,  1876.     [BlaMij  Will,  48  Wis.  294.) 

Seth  H.  Evitts  died  September  22,  1877,  aged  eighty  years.  On 
August  27, 1875,  he  executed  a  mil,  bequeathing  to  plaintiff  all  his  prop- 
erty with  the  exception  of  a  few  smaU  items.  On  April  2,  1876,  and 
September  22,  1876,  he  made  two  other  wills,  which  were  substantially 
the  same  as  the  will  of  1875,  the  only  change  being  in  the  minor  be- 
cpiests.  These  wills  were  severally  offered  for  probate,  but  rejected  on 
the  ground  that  testator  was  not  of  sound  mind  when  he  executed  them, 
and  the  will  of  1875  was  probated.  On  December  20,  1876,  deceased  exe- 
cuted a  deed  to  defendants,  transferring  most  of  his  real  estate.  His  deed 
it  is  now  sought  to  set  aside  on  the  ground  of  mental  incapacity  in  the 
grantor.  In  setting  aside  the  deed  the  Maryland  Court  of  Appeals  said,  in 
reviewing  the  evidence,  that  after  the  execution  of  the  win  of  September, 
1876,  the  defendants,  through  false  statements,  produced  in  the  mind  of 
deceased  an  insane  delusion  that  plaintiff  was  treating  him  badly  and 
robbing  him  of  his  property ;  that  he  had  always  been  on  affectionate 
terms  with  plaintiff ;  that  there  were  no  grounds  for  the  delusion ;  that 
he  had  several  strokes  of  apoplexy  in  1876,  and  was  permanently  paral- 
yzed ;  became  imbecile ;  was  childlike ;  had  few  ideas ;  his  mind  became 
inert ;  was  easily  controlled  and  influenced ;  his  memory  failed ;  was  un- 
able to  walk  without  assistance  and  required  constant  attendance ;  his 
hobby  was  politics.     (CJierionnier  vs.  Evitts,  56  Maryland  Reports,  276.) 

Epilepsy. — The  wills  of  epileptics  are  sometimes  contested.  In  the 
€ase  of  Ross  (12  N.  Y.  Weekly  Digest,  34)  the  will  was  made  in  an  inter- 
paroxysmal  period  and  was  sustained.  On  Ajjril  29,  1879,  the  testator, 
who  had  been  subject  to  attacks  of  acute  mania,  superinduced  by  epilep- 
tic convulsions,  was  committed  to  a  lunatic  asylum.  He  was  discharged 
May  12, 1879.  The  superintendent  of  the  asylum  testified  that  testator's 
mental  condition  was  then  good,  and  that  between  the  eijileptic  attacks 
he  was  of  sufficient  mental  soundness  to  understand  what  he  was  doing. 
On  May  21,  1879,  testator  executed  his  wiU.  His  familj^  physician  testi- 
fied that  he  was  then  of  sound  mind  and  memory,  and  capable  of  making 
a  wUl.  Testator  was  again  attacked  with  an  epileptic  convulsion  on  June 
11, 1879,  and  died  June  24, 1879.  Held  that  testator  was  sane  at  the  time 
the  will  was  made. 

The  following  case  is  somewhat  more  complicated,  pneumonia  with 
delirium  occurring  at  about  the  time  of  the  execution  of  the  will : 

Elizabeth  M.  Riggiu  was,  on  November  14,  1868,  at  the  age  of  sixty- 
two,  attacked  with  an  epileptic  fit,  and  rendered  unconscious ;  an  attack 
of  pneumonia  supervened  the  epileptic  fit,  accompanied  with  high  fever 
and  occasional  delirium,  during  which  she  would  be  unconscious.  Pre- 
vious to  her  illness  she  was  intelligent  and  cultivated,  robust  and  strong, 
though  nervous.  She  was  regarded  as  a  gifted  and  brilliant  woman. 
Witnesses  on  both  sides,  who  were  present  during  her  illness,  stated  that 
while  occasionally  out  of  her  mind,  at  other  times  she  was  rational  and 
intelligent,  her  mental  condition  being  cleaily  the  result  of  delirium 
attendant  on  high  fever.  No  witness  claimed  that  she  had  wholly  lost 
her  reason  at  that  period.  On  November  23, 1868,  she  executed  her  will. 
Between  that  time  and  her  death,  which  occurred  in  July,  1875,  she  exe- 
cuted three  codicils.     Each  of  the  witnesses  to  the  will  and  codicils  testi- 


I^\sAyJTy  ix  its  medico-legal  bearings.  123 

fied  to  the  sanity  and  intelligence  of  deceased  at  the  time  of  execnting- 
them.  On  the  trial  of  the  issues  in  the  Circuit  Court  of  St.  Clair  County, 
in  April,  1877,  before  a  jury,  it  "was  found  that  the  will  aiul  codicils  were 
not  tliose  of  the  testator,  Elizabeth  M.  Kiggin  ;  that  is  to  say,  that  she 
was  insane  at  the  time  she  executed  them,  and  they  were  therefore  null 
aiul  void.  On  appeal  to  the  Sui)reme  Court  of  Illinois  this  finding  was 
reversed.     {Uroirii.  vs.  liif/gi)i,  94  111.  R.  560.) 

Alroliolism. — The  will  of  a  confirmed  drunkard  will  stand  inlaw,  jiro- 
vided  the  person  who  made  it  is  not  in  a  condition  to  l)e  so  unreasonable 
and  irrational  as  to  be  unable  to  exercise  anything  like  healthy  judgment. 
A  man  may  be  a  hard  drinker,  and  inake  the  wiU  after  a  debauch,  but 
unless  its  character  is  so  absurd  as  to  betray  mental  unsoundness,  he 
cannot  be  reasonal)ly  deemed  irresponsible.  In  a  recent  case  in  which 
the  Avi'iter  ap])eai-ed,  the  testator  was  a  man  of  bad  habits,  who  drank 
immoderately  and  steadily.  Evidence  was  produced  to  prove  that  he 
had  done  all  manner  of  foolish  things  before  and  after  the  will  was 
made,  but  no  evidence  wds  brought  forward  to  show  that  at  the  time  the 
paper  was  signed  the  testator  was  in  any  condition  to  prevent  him  from 
fully  knowing  the  nature  of  what  he  was  then  doing.  We  are  to  con- 
sider in  such  cases  the  degTce  of  the  drunkenness,  the  habits  and  physical 
condition  of  the  person. 

A  case  fell  under  the  writer's  notice  two  or  three  years  ago,  the 
testator  being  a  nuiu  of  middle  age,  who  had  for  months  been  ad- 
dicted to  drinking,  although  in  a  periodical  way.  A  vague  history  of  bad 
temper,  broken  sleep,  and  many  extravagant  acts,  none  of  which,  however^ 
were  necessarily  manifestations  of  insanity,  was  testified  to  by  the  con- 
testants, and  one  physician  gravely  asserted  that  a  proof  of  the  mental 
perversion  consisted  in  the  irritability  of  the  testators  throat  during  the 
time  he  was  making  medicated  applications  to  the  same.  He  was  alleged 
to  have  declared  that  "  he  could  not  retain  anything  upon  his  stomach  "  ; 
that  '^he  resorted  to  memoranda  that  he  should  not  neglect  his  engage- 
ments " ;  that  "  he  al)used  the  doctor  who  had  treated  his  wife  during  her 
last  illness,  and  threatened  him  with  violence";  that  ''he  complained 
of  being  homesick " :  and  various  persons  who  had  seen  little  of  him 
testified  to  having  observed  him  drunk  on  several  occasions;  that  "he 
was  extravagant,  and  bought  large  quantities  of  oranges,"  which,  how- 
ever, were  for  his  sick  wife;  and  that  he  "talked  wildly  about  his  busi- 
ness." It  appeared,  on  the  other  hand,  that  he  was  able  to  attend  to  his 
affairs  for  some  time  before  his  death,  whi(?li  was  not  due  to  alcoholism ; 
that  when  he  made  his  will  it  was  at  a  time  between  two  of  his  sprees, 
and  that  thei-e  was  no  want  of  sagacity  or  any  irregularity  shown  in  the 
disposition  of  his  property.  In  this  case,  as  in  many  others,  the  popidar 
ideas  of  insanity  are  apt  to  be  thorouglily  ventilated,  and  it  is  strange 
that  tills  kind  of  testimony  should  receive  any  attention  whatever  in 
courts  of  law.  It  is  a  very  easy  matter  to  exaggerate  the  disorderly  be- 
havior of  an  individual  who  is  in  no  sense  insane.  The  "excitement" 
alluded  to  by  interested  witnesses  is  probably  nothing  nu')re  than  a 
moderate  emotional  exliilaration,  and  the  busint'ss  schemes  which  attract 
the  wonderment  of  those  who  wish  the  will  broken  ordinarily  display  a 
mind  of  unusual  shrewdness.  The  speculations  nearly  always  turn  out 
well,  and  the  despondency  does  not  rise  above  the  dignity  of  an  ordinary 
attack  of  the  blues.     In  the  above  case  the  husband's  devotion  to  his 


124  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

dying  Tvife  seemed  to  have  astonished  those  j)ersons  "who  appeared  upon 
the  side  of  the  contestants ;  and  this  pecnliar  behavior,  which  was  re- 
garded by  them  as  e^'idenee  of  mental  nnsoundness,  consisted  in  such 
kindly  offices  as  remo%dng  her  to  the  ^vindow,  so  that  she  might  get  the 
fresh  ail",  and  bringing  her  fi^nit ;  and  though  his  exuberation  of  affec- 
tion might  have  been  that  which  is  so  often  intensified  by  occasional 
libations,  it  was  in  this  case  nothing  nnusual.  It  did  not  appear  that 
there  was  anything  in  the  character  of  the  vnR  that  indicated  insanity ; 
l3ut  that  it  was  legally  witnessed,  and  made  at  the  tune  when  the  indi- 
vidual was  perfectly  sober,  and  was  therefore  very  properly  admitted  to 
l^robate. 

In  another  case  of  a  different  kind  the  patient  had  for  several  years 
indulged  in  large  quantities  of  alcohol,  and  it  was  common  for  him  to 
shut  himself  up  in  the  room  with  a  box  of  champagne,  and  not  leave 
nntil  he  had  recovered  from  the  effects  of  the  intoxication  produced  hy 
the  dozen  bottles  he  finished,  one  after  the  other,  in  rapid  succession. 
This  man,  for  several  years  before  his  death,  drank  all  kinds  of  hquors 
to  excess,  squandered  his  money,  giving  large  amounts  to  persons  who 
had  little  or  no  claim  upon  him,  and  betrayed  a  change  in  character 
which  was  remarkable  when  contrasted  viith  the  regularity  and  sobriety 
of  pre^"ious  years.  Within  a  short  time  before  his  death  he  manifested 
symptoms  of  the  inevitable  diseases  which  are  due  to  excesses  of  this 
kind,  and  he  finally  succumbed  to  cii'rhosis  and  died  comatose.  When 
suj^poi-ted  in  bed,  and  suiTOunded  by  those  to  whom  he  left  his  money, 
he  made  a  will  and  died  a  few  horu's  afterward.  This  will  was  verj^ 
properly  contested  by  his  brother,  and  it  was  admitted  to  probate  by  the 
suiTogate,  though  the  decision  of  the  latter  was  sulisequently  reversed. 
It  is  cpiite  likely  here  that  the  man's  mental  condition  was  one  which, 
€ven  some  time  before  his  demise,  would  prevent  him  from  pro^jerly 
recognizing  the  objects  of  his  bounty,  and  render  him  an  easy  prey  to 
designing  persons ;  but  a  will  made  under  more  outrageous  circumstances 
it  is  difficult  to  conceive  of,  for  he  was  literally  in  a  condition  of  extremis 
when  his  name  was  signed  to  the  document. 

The  following  is  a  case  of  alcoholism  where  a  mental  disturbance  ex- 
isted, with  delusions,  which,  however,  were  proved  not  to  relate  to  the 
wiQ  itself  or  those  who  were  to  be  benefited : 

Betsy  Marsh  died  April  7,  1876,  aged  sixty-five  years.  She  was  ec- 
centiic  in  di-ess  and  coarse  in  language.  Her  death  followed  a  short 
illness — undoubtedly  a  disease  of  the  brain,  which  gave  rise  to  frec[uent 
delusions.  These  delusions  appeared  only  occasionally.  On  the  3d  of 
Apiil,  1876,  she  executed  her  will,  and  stated  in  answer  to  a  question 
that  she  knew  what  she  was  doing,  and  later  in  the  same  day  sent  for  a 
Dr.  Kinch,  who  had  drawn  her  will,  to  make  some  alterations  in  it. 
These  alterations  were  never  made,  for  the  next  day  she  was  found  in- 
toxicated in  the  woods,  and  from  that  time  she  was  very  ill,  until  she 
suddenly  died  on  the  7th  of  April.  It  was  testified  that  deceased  was  of 
sound  mind  at  the  time  the  \r\]l  was  executed ;  that  her  delusions  were 
only  intermittent,  residting  from  her  disease,  and  that  they  consisted  of 
presentiments  of  death,  and  did  not  relate  to  any  person  who  might  have 
been  an  object  of  her  bounty.  The  "wiU  was  admitted  in  the  Union 
County  Oi-jDhans'  Com-t,  and  on  appeal  to  the  Prerogative  Com-t  this 
action  was  affii-med. 


INSANITY  IN  ITS  MEDICO-LEGAL  BEAIilNGS.  125 

In  chronic  alcoholism  with  organic  brain  diseases  but  no  alleged 
insanity  the  question  of  responsiljility  naturally  arises.  In  most  cases 
■of  advanced  structural  disease  the  charactter  of  the  testator  undergoes  a 
series  of  changes  which  render  him  wxuik,  vacillating,  childish,  and  with- 
out vigorous  memory.  At  such  times  it  is  extremely  probal)lc  that  the 
person  is  a  prey  to  designing  relatives  and  suffers  enfeeblement  of  the 
"will. 

Care  should  be  taken  not  to  confuse  the  mental  impairment  of  old 
age  or  eccentricity  with  the  2)eculiarities  of  disposition  aiid  ha1)its  result- 
ing from  chronic  alcoholism.  {Lee  vs.  Scudder,  31  N.  J.  Equity  Reports, 
633.) 

Undue  Influence. 

A  much-abused  term,  which,  however,  has  an  important  legal  value, 
is  what  is  known  as  undue  influence.  Just  how  much  i)i'essui"e  may  be 
considered  undue  is  of  course  a  matter  for  judges  and  juries  to  decide  ; 
jet  it  is  a  grave  question  whether  any  one  is  capable,  without  a  deep  in- 
sight into  the  character  and  mode  of  life  of  a  particular  individual,  to 
■estimate  his  susceptibility  or  powers  of  resistance,  and  to  say  how  much 
he  has  been  made  to  do  anything  against  his  will  and  at  the  dictation  of 
others.*  It  is  at  best  an  awkward  term,  and  should  be  done  away  with. 
The  relation  of  human  beings,  and  the  doctrine  of  the  survival  of  the 
fittest,  presume  the  existence  of  individuals  of  varying  mental  attributes 
— some  who  receive  suggestions  more  readil}^  than  others,  and  who  lack 
individuality,  others  who  shirk  effort,  and  others  whose  suscej)tibility  to 
■emotional  excitement  and  affective  influence  is  very  great.  It  is  there- 
fore of  vital  importance  to  establish  the  existence,  if  possible,  of  actual 
insanity  and  a  prolonged  departure  from  the  former  habits  of  life. 

Medical  witnesses  are  frequently  asked  to  express  an  opinion  whether 
the  patient's  mental  disease  is  not  such  as  to  make  him  an  easy  prey  to 
■designing  friends  and  relatives,  who  may  have  ends  of  their  own  to  gain, 
and  through  the  agency  of  undue  influence  may  lead  or  force  the  person 
to  dispose  of  his  propertj^  in  a  way  he  would  not  were  he  in  full  posses- 
sion of  his  faculties.  It  is  sometimes  a  difficult  matter  to  give  such  an 
opinion,  for  although  the  physician  may  have  no  doubt  of  the  mental 
status  of  the  testator,  he  is  often  bound  by  rules  of  evidence  to  answer  a 
badly  drawn  hypothetical  question  which  is  unscientific  and  negative. 
Undue  influence  may  be  brought  to  bear  in  cases  where,  through  disease, 
the  individual  is  either  unable  to  reason  correctly,  or  where,  to  avoid 
opposition  and  worry,  he  injudiciously  accepts  the  arrangements  made 

*  Johnson  vs.  Arnisfronr/,  97  Ala.  731.  Jol\n  C.  Johnson  died,  aged  seventy,  in 
January,  1891.  Will  was  executed  September  20,  1890.  In  1879  he  was  stricken  with 
paralysis,  his  health  and  mind  becoming  impaired.  In  consequence  his  moral  nature 
changed,  and  he  took  a  woman,  whom  he  claimed  was  his  illegitimate  daugliter,  to  his 
home  and  lived  illicitly  with  her  until  1880,  when  he  became  estranged  from  his  nine 
children  and  removed  to  another  county,  where  he  continued  to  live  witli  the  woman 
Tuitil  he  died,  children  being  born  to  them.  There  was  some  evidence  as  to  acts  and 
peculiar  conduct  of  deceased,  quarrels  with  his  children,  his  wife,  and  others.  Tlie 
probate  of  tlie  will  was  refused  by  the  Probate  Court,  and  on  appeal  the  Supreme 
Court  reversed  the  judgment  on  tlie  ground  that  undue  influence  had  not  been  proved, 
and  that  tliere  was  not  sufficient  ])roof  that  .Idhnson  was  insane  when  the  will  was 
•executed,  habitual  and  fixed  insanity  not  liaving  been  proved. 


126  ^   SYSTEM  OF  LEGAL  MEBLCLXE. 

by  otlier  peo^jle,  or  where  Ms  Trill-in ovrer  is  so  luiieli  imjiaii-pcl  that  he 
eanuot  resist  well-dii'eeted  and  decisive  demands  of  interested  plottei'^. 
The  suspiciousness  and  unreasonable  delusions  -which  the  insane  man 
harliors  toward  those  he  has  always  lovf d  are  very  often  played  upon 
by  interested  persons,  and  in  certain  stages  of  delusional  insanity,  as 
well  as  the  fii'st  stage  of  dementia,  it  is  possible  to  lead  the  insane  indi- 
-sddual  to  do  many  unjust  acts,  under  the  delusion  that  indignities  have 
been  heaped  upon  him,  and  that  insults  and  shghts  have  been  offered  to 
him.  It  may  readily  be  seen  how  the  subject  of  rehgious  melanchoha 
may  be  made  to  give  all  his  money  to  the  church,  and  instances  of  this 
kind  are  exceedingly  common,  esjiecially  when  the  testator  is  a  woman 
who  is  tortui'ed  with  ideas  of  futui'e  uni-est  and  punishment.  The  major- 
ity of  cases  where  undue  iirfiuence  is  alleged  to  have  been  exercised  ai*e 
those  where  there  is  a  history  of  dementia  in  old  people.  The  senile 
dement  is  prone  to  make  fooUsh  and  tl'i^*ial  disposition  of  his  jjroperty, 
and  particularly  is  this  the  case  when  he  is  aicled  by  designing  people 
who  surround  him ;  and  the  indi^idual  of  this  kind  is  very  apt  to  be 
easily  tiu'ued  fi*om  his  original  purpose  by  fresh  suggestions  or  new 
influences.     He  is  liable  to  imposition  and  unjustifiable  prejudice. 

In  paretic  dementia  the  ^ictim  is  very  likely  to  squander  his  prop- 
erty and  to  faU  a  prey  to  the  many  parasites  who  are  eA^er  ready  to  take 
advantage  of  Ms  bonhomie  and  boastful  good  natiu-e.  In  a  recent  case 
the  paretic,  whose  illusions  of  gi-andeiu'  were  of  the  most  magnificent 
character,  became  involved  in  a  variety  of  schemes  demised  by  ingemous 
sharpers,  and  when  legal  proceedings  were  instituted  it  was  found  that 
he  had  gone  so  far  as  to  buy  for  Ms  new  fiiends  a  cargo  of  bric-a-brac, 
and,  to  seciu-e  a  place  for  the  sale  of  the  same,  he  had  bought  up  the 
stock  of  the  occupant  of  the  store,  siiending  $30,000.  so  that  his  fi-iends 
might  take  immediate  jnossession.  In  patients  suffering  fi'om  the  fii'st 
stages  of  the  disease  it  may  readily  be  seen  how  any  one.  by  judicious 
flattery  and  accpiiescence  in  the  startling  projects  and  ideas  of  the  indi- 
^ddual,  may  wheedle  him  into  parting  with  property. 

In  other  forms  of  organic  insamty  a  condition  of  mental  feebleness 
akin  to  dementia  is  manifested  by  ii-resolution,  ii-ritability,  or  intellectual 
torpor.  It  will  frecpiently  be  found  that  disease  of  the  cerebral  vessels, 
especially  on  the  left  side  of  the  brain,  is  very  apt  to  be  followed,  if  at 
all  extensive,  by  degeneration  of  the  mental  faculties ;  and  if  such  degen- 
eration has  au  early  fatal  ending,  and  a  biased  and  mijust  will  is  made, 
even  though  there  can  be  brought  forward  very  few  instances  of  mental 
ii-regularity,  we  should  still  question  the  abihty  of  the  patient  to  with- 
stand the  arguments  of  interested  fi'iends.  Sof temng  is  so  common  after 
accidents  of  the  kind  mentioned  above,  and  is  so  frequently  symptom- 
atized  hj  loss  of  memory,  indecision,  and  childishness,  that  intellectual 
competencA^  should  always  be  questioned. 

On  October  12, 1872,  Mrs.  Elizabeth  Greenwood,  tlien  sixty-two  years 
old,  executed  her  wiU.  She  died  August  9, 1875,  leading  an  estate  worth 
$26,000.  By  the  terms  of  her  AA-ill  she  bequeathed  to  two  of  her  children, 
Eliza  Smith  and  William  Greenwood  (the  contestants),  $100  each,  and 
the  residue  of  her  estate  to  Olive  Xewsome,  a  granddaughter,  and  Mrs. 
Mary  Cline,  her  remaining  child.  The  will  was  contested  on  the  gi-ound 
that  the  testator  was  of  weak  mind  at  the  time  it  was  executed,  and  un- 
duly influenced.     It  was  not  claimed,  however,  that  she  was  incapable  of 


I^'SJ^'ITY  IN  ITS  MEDICO-LEGAL   BEARINGS.  127 

oxccnitiiifjj  tlic  will,  Ijiit  that  she  was  lahoriii^'  uiuhT  a  iMusioii  with 
regfird  to  contestants,  l)roiij;ht  ahout  by  the  undue  influence  exercised 
u})on  her  weak  and  ini})aired  mind  by  Mrs.  (line  and  Mrs.  Xewsojne. 
Upon  the  trial  of  tlie  issues  in  the  County  Court  the  will  was  rejected, 
the  court  holding-  that  while  deceased  had  testamentary  capacity,  the  will 
was  executed  under  undue  infiuenee.  On  appeal  to  the  Circuit  Court 
this  judgment  was  reversed,  and  contestants  then  ai)pealed  to  the  Supreme 
Court,  wlio  I'eversed  the  judgment  of  the  Circuit  Court  and  rejected  the 
will,  on  the  same  ground  taken  l)y  tlu;  County  Court,  and  also  sustained 
the  <'laim  of  contestants  that  deceased  was  lal)oring  under  a  delusion 
regarding  them  at  the  time  she  executed  the  will.  The  evidence,  which 
is  voluminous,  shows  that  deceased  had  a  severe  attack  of  paralysis  in 
18G(),  from  the  effects  of  which  she  never  recovered ;  that  her  memory 
became  defective;  she  could  not  tell  who  was  working  for  her;  would 
lease  a  piece  of  land  and  forget  it  next  day  ;  would  ask  the  same  question 
repeatedly.  Two  medical  doctors  who  had  known  deceased  testified  that 
she  was  very  despondent ;  was  different  from  the  majority  of  people ;  at 
times  exhibited  mental  obliquity ;  her  mental  powers  were  impaired. 
Others  testified  that  her  eyes  had  a  dead  expression ;  she  sometimes  acted 
like  an  intoxicated  person ;  in  1872  she  was  peculiar  in  her  conversation ; 
would  stop  short  while  making  a  remark,  and  fail  to  finish  it;  was 
absent-minded ;  while  ill  she  imitated,  with  empty  hands,  the  action  of  a 
person  breaking  a  piece  of  quartz  and  examining  for  gold ;  she  very 
readily  gave  up  her  opinions,  and  would  side  with  anybody  who  disputed 
them  ;  that  while  going  from  Salem  to  Howell's  Prairie  alone,  she  became 
turned  around  in  the  road  and  was  coming  back  to  Salem  without  know- 
ing it ;  that  slie  did  not  appear  cheerful,  or  laugh ;  paid  no  attention  to 
her  housework ;  she  was  frequently  told  that  her  mind  was  not  right ; 
that  on  the  day  slie  executed  her  will  she  submitted  herself  to  a  short 
examination  by  two  doctors,  from  whom  she  obtained  a  certificate  of  her 
sound  mind  and  competency  to  make  a  will ;  that  Mrs.  Cline  by  means 
of  a  pretended  communication  from  her  deceased  husband,  obtained 
through  a  spiritual  medium,  stating  that  her  son  William  was  a  rough 
character  and  would  squander  her  property,  and  that  she  should  get  it 
all  out  of  his  hands,  produced  a  delusion  in  her  mind  regarding  the 
character  of  her  son.  There  was  some  evidence  on  behalf  of  proponents 
regarding  tlie  sanity  of  deceased,  but  as  this  was  admitted  it  is  not  neces- 
sary to  give  a  rhmne  of  the  evidence.  The  will  was  rejected  on  the 
ground  of  undue  influence — that  it  was  the  offspring  of  a  delusion  re- 
garding the  contestants.     {Greenwood  vs.  Cline,  7  Oregon  Reports,  17.) 

Hypnoti.sm. — Since  the  revival  of  interest  in  hypnotic  suggestion 
and  the  attention  paid  to  the  subject  by  the  newspapers,  the  claim  has 
been  frequently  advanced  in  courts  of  law  that  certain  unsatisfactory 
wills  were  made  by  decedents  who  were  unduly  influenced  by  hypnotism. 
After  much  research  I  am  unal)le  to  find  a  single  authenticated  ease  of 
the  kind,  but,  on  the  other  hand,  rather  a  great  deal  that  shows  how 
ignorance  and  ])rejudice, flourish,  as  they  did  in  what  were  supposed  to 
be  less  enlightened  ages.  As  a  rule  no  mention  is  made  of  hj^Dnotic  sug- 
gestion until  after  the  will  is  found.  That  a  person  can  be  made  to 
perform  an  unjust  act  through  the  suggestion  of  others  is  of  course 
possible ;  but  as  a  rule  the  suggestion  must  be  an  abstract  one,  that  is, 
provided  the  subject  is  possessed  of  ordinary  mental  health  and  normal 


128  A  SYSTEM  OF  LEGAL  MEDICINE. 

independence  of  will.  It  is  quite  possible  that  while  actual  hypnotic  un- 
consciousness is  not  produced,  an  old  person  may  make  an  unjust  will 
thi-ough  the  constant  suggestion  of  an  idea  by  interested  persons.  Such 
acts  are  common  ;\-ith  aged  people  who  fall  into  the  hands  of  shai-pers, 
cure-alls,  or  disreputable  exhorters.  The  experiments  of  investigators 
shoidd  certainly  go  to  show  that  it  is  impossible  or  extremely  difiacult  to 
make  hjqDnotized  subjects  do  things  that  are  naturally  repugnant  to 
them.  The  suggestion  of  disrobing  was  made  to  a  number  of  women, 
half  of  whom  were  of  known  immoral  character.  The  virtuous  women 
would  not  do  so,  but  the  others,  -N^-ithout  hesitation,  took  off  their  things. 
Possibly  a  determined  induction  of  hj^Duotism  might  throw  a  testator 
into  an  iiTesj)onsible  condition,  when  his  Ttih  would  be  subservient  to 
that  of  another ;  but  he  would  be  very  likely  afterward  to  question  and 
regret  the  nature  of  his  act.  It  may  be  said  that  insane  people  are  with 
difficulty  hj^^notized ;  so  if  insanity  is  alleged  as  a  contributory  part  of 
the  incapacity  it  -odll  be  important  to  determine  the  extent  of  attention 
possible. 

Suicide. 

The  validity  of  the  wiU  of  a  suicide  is  sometimes  questioned  by  reason 
of  alleged  uisanitj^  The  last  hom-s  of  most  suicides  are,  as  a  rule, 
marked  by  some  expression  which  will  enable  one  to  determine  the 
probable  mental  state.  De  Boismont,  Winslow,  and  others  have  collected 
an  immense  number  of  wi'itten  expressions  of  suicides,  and  the  former 
has  gotten  together  over  three  hundred  and  twenty  letters  which  show 
the  most  diverse  forms  of  mental  tortm-e.  Eighty-five  T^-ills  were  col- 
lected by  this  observer,  the  greater  number  shoA^'ing  clear  and  intelli- 
gent disposing  power;  and  it  does  not  follow  that  because  a  suicide  has 
X)robably  sho^vn  peculiarities  of  conduct  before  his  death  he  has  lost  the 
power  to  discriminate  in  the  matter  of  choosing  the  objects  of  his 
bounty.  On  the  other  hand,  there  are  many  wills  made  by  suicides 
that  are  irrational  and  absurd — some  of  which  contain  clearly  insane 
directions  in  regard  to  the  disposal  of  the  body,  the  personal  effects,  etc. 
These  should  always  be  received  ^ith  great  caution. 

CONTRACTS. 

The  plea  that  a  contract  has  been  entered  into  by  a  person  when  in 
an  irresponsible  state  is  often  urged.  In  contracts  that  are  disputed 
because  of  the  alleged  insanit}^  of  one  of  the  parties  it  is  necessar}-  to 
examine  not  ovlj  the  individual,  but  the  instrument.  If  it  is  discovered, 
in  addition  to  the  insanity  of  the  contracting  party,  that  the  bargain  is 
clearly  disadvantageous  to  him,  the  question  of  fraud  and  imposition  is 
raised.  It  sometimes  happens,  on  the  other  hand,  that  the  question  of 
mental  unsoundness  is  agitated  when  it  is  the  aim  of  a  j^erson  to  shirk  a 
responsibihty.*     In  a  recent  case  in  which  the*  ATOter  appeared,  the  ques- 

*  Lillji  vs.  Waogoner,  27  HI.  395.  Bill  to  set  aside  conveyance  of  real  estate,  by 
George  Waggoner,  conservator  of  Elisha  Waggoner.  In  ]S51  Elislia  Waggoner  con- 
veyed real  estate  to  A.  Lilly.  In  1858  an  incjuest  declared  Elisha  insane,  and  George 
was  apijointed  eonsei-A^ator  of  his  estate.  It  was  alleged  that  "  for  a  long  period  pre- 
vious to  the  inquest "  in  1858  Elisha  was  insane,  but  there  was  no  i)ositive  proof.     Oil 


INSANITY  IX  ITS   M KhlCO-LEGAL   JiEAUlMJS.  129 

tioii  of  Tnolancholia  was  iir<i-('(l,  and  it  was  averred  that  the  l)h^illtiff  had 
made  a  (ioiitract  under  the  impression  that  liis  husincss  was  in  a  ruiiKMis 
condition,  and  that  tliis  was  a  dehision  resulting'  ti'om  niehineliolia.  In 
this  ease  I  Avas  unable  to  find  any  eharacteristit;  intellectual  deranjiement, 
hut  only  simple  emotional  disturljance  of  a  depressing  character.  I  found 
that  his  view  of  the  state  of  his  affairs  was  perfectly  in  accordance  with 
the  real  facts ;  that  the  contract  was  dictated  hy  him  and  contained  perti- 
nent marginal  corrections  and  interlineations ;  that  his  letters,  written 
at  the  time,  were  intellii^-ent ;  and  that  his  jnotives  in  Ijriuginy  the  siiit 
were  to  upset  a  ])argain  that  did  not  bring  him  subsequently  what  he 
considered  to  be  his  proper  share  of  the  business  he  conducted  with  the 
contracting  parties.  We  must  take  cognizance  of  the  fact,  in  such  cases 
as  this,  as  well  as  others,  that  no  question  of  the  insanity  existed  at  the 
time  of  the  alleged  imposition ;  that  usually  the  friends  of  the  person  do 
not  consider  it  necessary  to  seek  legal  advice,  and  it  is  not  necessary  to 
resort  to  an  asylum  or  other  means  of  protection.  Casper  relates  a  case 
of  interest  in  this  connection  :  "  In  a  civdl  process  the  accused  merchant, 
W.,  asserted  that  from  his  ailing  condition  he  was  unable  to  prepare  a 
statement  of  his  affairs  and  to  confirm  it  by  an  oath.  I  had  to  satisfy 
myself  in  regard  to  this,  and  at  the  same  time  to  give  an  oi)ini<)n  whether 
he  could  be  arrested  personalh',  if  necessary.  The  investigation  proved 
that  W.  certainly  labored  under  the  weU-known  disease  called  Iniiochon- 
dria,  wdiicli  in  itself  could  be  regarded  as  a  mere  simulation,  though  it 
could  not  be  denied  that  the  manifold  ailments  alleged  to  exist  were 
either  intentionally  or  unintentionally  exaggerated.  '  Granting,  how- 
ever,' I  said,  '  that  W.  is  ill,  nevertheless,  since  he  is  not  feverish  nor  con- 
fined to  bed  and  is  of  clear  intellect,  it  is  not  easy  to  see  why  such  an 
employment  as  the  one  in  question — the  preparation  of  a  statement  of 
his  affairs  in  his  own  apartments — should  be  impossible  for  him  or  likely 
to  be  injurious.  When  he  alleges  that  the  mere  addition  of  sums  causes 
him  anguish,  such  a  statement  is  to  be  rejected  as  inconsistent  -sWth  med- 
ical experience.  Only  if  he  were  to  be  forced  and  hurried  in  the  per- 
formance of  such  a  work  could  there  be  a  possibility  of  iujmy  resulting.' 
Accordingly  I  declared  that  W.  was  in  a  fit  condition  to  prepare  a  state- 
ment of  his  affairs  and  to  confirm  it  by  oath,  provided  a  few  weeks  were 
granted  to  him  for  this  purpose,  and  that  if  necessary  he  might  be  per- 
sonally arrested.  This  ojnnion  was  communicated  to  W.,  and  a  state- 
ment of  his  affairs  was  very  speedily  thereafter  handed  in." 

William  L.  Rusk,  who  had  previously  been  successful  in  business  in 
the  city  of  Baltimore,  and  was  remarkable  for  his  energy  and  iudustiy 
and  shrewdness,  was,  on  April  19,  18G1,  suddenly  thrown  into  a  condi- 
tion of  intense  excitement,  caused,  it  was  believed,  hy  the  military  prep- 
arations and  excitements  of  those  times.  He  remained  in  this  e(mdition 
for  some  tune,  and  was  removed  to  the  residence  of  his  sister,  and  finally, 

the  other  hand,  it  was  shown  tliat  Elisha  had  been  engaged  in  numerous  other  trans- 
actions about  1S51,  in  all  of  which  he  appeared  rational;  that  he  '"was  about  like 
the  other  Waggoners — was  always  somewhat  singular."  One  medical  witness  testified 
that  "  if  there  was  reason  for  it,  there  would  appear  to  be  some  marks  of  simulated  in- 
sanity." The  land  had  ris^n  from  foiu-  to  twenty  dollars  per  acre,  and  the  court  re- 
garded this  as  a  reason.  The  Circuit  Court  decided  that  the  deed  was  void,  but  on 
appeal  the  Supreme  Court  reversed  the  decree  and  dismissed  the  bill,  holding  that 
Elisha  was  not  insane  at  the  time  of  the  conveyance. 


130  ji   SYSTEM  OF  LEGAL   MEDICIXE. 

in  the  latter  part  of  May,  -vras  admitted  to  have  been  insane.  His  disease 
-was  declared  to  be  a  case  of  general  Ijrain  trouble,  caused  by  the  finan- 
cial excitement,  etc.,  of  that  period.  On  December  27,  1862,  while  resid- 
ing with  his  SLSter,  he  executed  a  deed,  for  a  nominal  consideration,  of 
jjroperty  valued  at  upwai'd  of  $10,000,  to  Eobert  Turner,  in  trust  for  his 
mother.*^  who  was  then  sevent^'-fi.ve  years  old,  and  after  her  death  abso- 
lutelv  to  his  sister.  He  left  his  sister's  in  1864,  and  lived  with  his  mother 
until  1875,  when  she  died,  and  after  her  death  the  cestui  que  trust  claimed 
the  ijroperts*  named  in  the  deed.  He  then  brought  suit  to  have  the  deed 
set  aside  on  the  ground  that  he  was  not  mentally  capable  of  making  a 
valid  deed  at  the  time  it  was  executed,  and  the  deed  was  declared  void. 
It  was  shown  that  although  the  propert\^  stood  assessed  in  his  name 
no  mention  of  the  ti'ansf  er  had  ever  been  made  to  Mm,  and  he  claimed 
to  have  no  recollection.  It  was  also  proved  that  he  was  incaj^able  of 
transacting  business  at  the  time  of  the  execution  of  the  deed,  and  that 
he  had  not  completely  recovered  from  the  effects  of  his  attack  in  1861 
nntil  several  years  thereafter.  On  appeal  to  the  Court  of  Appeals  the 
judgment  declaring  the  deed  void  was  affirmed.  {Turner  vs.  Busl',  53 
3Iaryland  Reports,  65.) 

The  jjrotection  of  person  s  who  deal  in  good  faith  with  lunatics  has  been 
assured  *  when  the  contract  has  been  equitable  and  there  was  nothing  in 
the  manner  of  the  alleged  lunatic  to  attract  attention  to  his  condition. 
Should  the  person  take  advantage  of  the  sujjposed  lunatic,  he  having- 
been  apprised  of  his  state  of  mind,  of  course  the  contract  may  be  set  aside. 
In  fact,  fraud  of  all  kinds,  when  X->roved,  is  a  barrier  to  the  claims  of  those 
who  seek  to  avoid  obligations  incurred  with  persons  of  weak  mind. 

TJie  JJegree  of  Unsoundness. — The  degi-ee  of  unsoundness  necessary  ta 
invahdate  a  eonti-act  as  fixed  hy  the  law  is  imcertain  and  indefinite.  The 
requirement  of  sufficient  intelligence  upon  the  part  of  the  contracting 
Xjarty  to  know  the  nature  of  his  act,  however,  no  matter  what  may  be 
the  foi-m  of  mental  disease,  is  aU  that  is  demanded.  He  may  be  an  im- 
becile or  idiot,  but  unless  the  latter  condition  be  an  extreme  one  he  does 
not  escape  the  obligation  iucurred.  His  estate  is  liable  for  debts  con- 
tracted to  supxjly  his  immediate  needs,  and  he  or  his  administrator  may 
be  sued.  He  is  also  liable  for  debts  contracted  during  his  lucid  inter- 
vals, but  no  infeiTcd  insanity,  such  as  is  ui'ged  in  the  fact  of  his  having 
been  in  an  asylimi  and  discharged,  is  sufficient  proof  of  his  recoveiy. 
(Wharton  and  Stille.j  The  contracts  made  by  a  lunatic  dui'ing  life  are 
void;  but  the  incapacity  must  be  proved,  for  the  obvious  reason  that 
there  may  have  been  only  a  partial  incapacity  during  life.t  In  such 
cases  the  administrator  may  be  held  liable.  There  are  decisions  which  have 
held  that  any  conti-acts  executed  by  lunatics  are  in  themselves  void.t 

*  Jenkins  vs.  Morris,  L.  K.  14  Ch.  D.  674 ;  Mitchell  vs.  Kingman,  5  Picli.  431 ;  etc. 

t  Ducker  vs.  JVIdtson,  112  X.  C.  44.  This  was  an  action  brought  against  "Wliitson 
as  administrator  of  W.  R.  Murray,  by  heirs  of  said  Murray,  to  whom  he  in  his  lifetime 
had  executed  notes,  with  a  -n-ritten  agreement  that  they  were  to  be  paid  out  of  his 
estate  after  his  death.  The  defense  was  that  at  tlie  time  the  notes  were  executed  he 
was  weak  in  body  and  mind,  and  not  mentally  capable  of  making  a  contract.  There 
was  evidence  that  he  had  made  other  contracts,  had  been  justice  of  the  peace  and 
postmaster,  and  attended  to  his  duties.  There  was  also  much  other  testimony  as  to- 
his  mental  capacity,  the  details  of  which  are  not  stated  in  the  report.  Judgment  for 
plaintiff  affirmed. 

X  Curtis  vs.  BrowneU,  42  Mich.  165.     This  was  a  bill  to  set  aside  a  mortgage,  on. 


JySA^UTY  IX  ITS  MICDKJO-LlidAL   JlJJJJnXdS.  131 


Marriage  and  Insanity. 

It  sometimes  happens  that  an  attemi)t  is  made  to  invaUdate  a  mar- 
riage^ one  of  the  contracting-  parties  being-  alh^ged  insane.  It  may  be 
that  the  person  in  whose  aid  the  power  of  the  courts  may  be  exercised 
is  at  the  tiine  of  marriage  a  d(!clared  hmatic,  in  which  case  all  that  is 
required  is  a  sliowing  of  the  linding-  of  a  previous  commission.  More 
often  the  contracting  party  is  one  of  weak  mind,  who  has  been  entrapped 
))y  designing  persons.  The  same  influences  that  may  have  been  Ijrought 
into  play  to  make  a  man  link  himself  with  some  prostitute  or  adventu- 
ress nuiy  be  brought  to  bear  to  make  him  an  earnest  defendant  when 
his  family  bring  action  to  set  aside  the  marriage.  In  such  a  case  he  is 
ami)ly  provided  with  friends  and  advice,  who  supply  the  brains  he  un- 
fortunately does  not  possess.  It  will  be  readily  seen  that  the  sexual 
perversion  inseparable  from  various  forms  of  insanity  may  lead  to  a 
union  perhaps  with  some  one  far  beneath  him,  and  in  the  other  sex 
the  influence  of  nymphomania  leads  to  impulsive  acts  which  the  per- 
son, who  perhaps  is  an  hysterical  girl,  does  not  stop  to  consider.  The 
-celebrated  English  case  of  Miss  Bagster  is  an  example  of  this  kind. 
"  Miss  Bagster  was  proved  by  the  evidence  to  be  a  frivolous  and  weak- 
minded  girl,  whose  education  had  been  much  neglected.  She  was  a  lady 
of  fortune,  and  she  ran  away  with  and  was  married  to  a  Mr.  Newton. 
An  application  was  made  by  her  family  to  dissolve  the  marriage  on  the 
ground  that  she  was  of  unsound  mind.  Among  other  facts  urged  before 
the  commission  as  proof  of  the  allegation,  it  was  mentioned  that  she  was 
occasionally  violent  and  self-willed,  that  she  was  passionate  as  a  child, 
and  that  even  in  maturer  years  she  had  little  or  no  self-control ;  that 
she  was  ignorant  of  aritlimetic,  and  therefore  incapable  of  taking  care  of 
her  propert}^ ;  that  she  had  some  erotic  tendencies,  which  were  evinced 
by  her  want  of  womanly  delicacy,  and  by  her  having  engaged  herseK, 

the  gi'oimd  of  insanity  of  the  mortgagor  at  the  time  of  its  execution,  to  secure  pay- 
ment for  a  set  of  mill  machinery.  The  evidence  showed  that  he  had  been  engaged  in 
business  all  his  life,  and  managed  a  farm  and  other  interests.  He  had  always  been 
visionary  and  speculative ;  had  various  absurd  schemes  ;  planned  great  improvements 
in  his  neighborhood  ;  had  periods  of  exaltation,  and  of  depression,  when  he  feared  des- 
titution ;  planned  to  manufacture  pianos  and  furniture ;  to  build  a  town  on  an  adja- 
cent farm,  with  a  church  and  school ;  claimed  to  have  invented  an  excavating  machine  ; 
talked  of  setting  up  a  woodyard  in  his  village,  and  atten^pted  to  make  contracts  for 
wood;  and  claimed  he  had  $80,000  at  his  command.  The  mortgage  was  made  in  No- 
vember, 1875.  In  the  following  spring  he  committed  suicide  under  peculiar  circum- 
stances. At  times  when  he  indulged  in  his  extravagant  talk  and  actions  he  was  pale 
and  haggard.     Judgment  for  plaintiff  affirmed. 

Ldiieaster  Coinifi/  Jicnik  vs.  Moore,  78  Pa.  St.  407.  On  December  30,  1871,  George 
H.  Moore,  a  man  of  jiroperty,  about  fifty-four  years  of  a^ge,  called  at  plaintiff's  bank, 
and  obtained  the  discount  of  two  notes  signed  by  him,  amounting  to  $1000,  the  money 
being  placed  to  his  credit  and  afterward  cheeked  out  by  him.  Tins  money  lie  applied 
to  the  pajnnent  of  a  debt.  There  was  nothing  in  his  acti(uis  to  warn  the  officers  of 
the  bank  as  to  his  mental  condition.  On  June  5,  1872,  de  hoiolico  proceedings  were  in- 
stituted, and  on  Augtist  10,  1872,  inquisition  returned  that  Moore  was  a  lunatic,  and 
had  been  for  three  years  past.  In  this  action  to  recovei-  on  the  notes,  Moore's  insanity 
at  tlie  time  the  notes  were  executed  was  set  up  as  a  defense.  There  was  no  evidence 
of  Moore's  insanity  bej'ond  the  record  of  the  proceedings  in  hmacy  and  neighborhood 
reports,  which  latter  it  was  held  were  not  sufficient  to  constitute  notice  to  the  V)ank. 
Verdict  for  defendant,  which  was  reversed,  the  Supreme  Coiu-t  holding  that  '-the  law 


232  ^   SYST£Ar  OF  LEGAL  MEDICLXE. 

■witli  a  view  to  marriage,  to  several  individuals.  Ou  her  examination 
before  the  commissioners  her  answers  were  intelligent,  and  her  conduct 
in  no  way  different  from  that  of  ordinary  individuals.  Seven  medical 
witnesses  were  summoned  to  sujDport  the  commission,  and  each  of  them 
deposed  that  she  was  of  unsound  mind.  The  commissioners,  however, 
had  recourse  to  Drs.  Morrison  and  Haslam,  who  visited  her,  and  who 
came  to  the  conclusion  that  she  was  neither  imbecile  nor  idiotic,  and 
that  her  inability  to  manage  her  affairs  arose  from  ignorance.  She  was- 
aware  of  her  deficiencies,  and  deplored  her  ignorance  of  arithmetic,  and 
explained  it  ou  the  ground  that  her  grandfather  had  been  too  ready  to 
send  excuses  for  idleness  when  she  was  at  school.  Her  conversation 
greatly  impressed  Drs.  Haslam  and  Morrison  with  a  belief  in  her  sanity. 
The  juiw,  iDy  a  majority  of  twenty  to  two,  retm-ned  a  verdict  that  Miss- 
Bagster  had  been  of  unsound  mind  since  November,  1830,  and  the  mar- 
riage was  consequently  dissolved." 

Breach  of  Promise  and  Insanity. 

Breach-of -promise  cases  are  often  defended  upon  the  plea  of  insanity 
and  irresponsibility.  In  the  case  of  Harford  vs.  Singleton,  it  was  claimed 
that  the  defendant's  softening  of  the  brain  and  insanity  were  cogent  rea- 
sons  for  his  non-fulfillment  of  the  marriage  contract,  which  plea,  how- 
ever, was  unsuccessful.  This  action  was  defended  on  the  ground  that  at 
the  time  defendant  had  promised  marriage  he  was  advanced  in  life,  viz., 
sixty  years  of  age ;  and  that  before  a  reasonable  time  had  elapsed  from 
the  request  to  marry,  namely,  in  May,  1855,  he  was,  by  a  "  visitation  of 
God,"  attacked  by  a 'fit  of  apoplexy-,  since  which  time  he  was  in  an  infirm 
state  and  afflicted  with  softening  of  the  brain,  in  consequence  of  which 
he  could  not  perform  his  promise  without  puttuig  his  life  in  great  j^eril 
and  hastening  his  death.  Evidence  was  called,  on  the  part  of  the  plaint- 
iff, to  prove  the  engagement  and  to  shoAv  that  no  apparent  impah-ment 
of  health  or  vigor  remained  after  recovery  from  the  attack.  It  was  stated 
by  defendant's  counsel,  Mr.  BaU,  that  in  1849  he  had  suffered  from  di-opsy 
aiid  disease  of  the  kidneys :  that  in  1852  he  had  an  attack  of  apoplexy 
and  congestion  of  the  brain ;  diu'ing  the  inter^'al  from  that  tune  until 
May  last"  he  had  promised  to  marry  the  plaintiff ;  Imt  that  in  the  latter 
month  he  was  afflicted  with  another  attack  of  apoplexy,  and  was  now 
suffering  from  paralysis  and  softening  of  the  brain.  The  defense  then 
called  several  medical  men  who  had  attended  the  defendant.  They  tes- 
tified that  he  had  had  apoplexy  and  was  paraMic,  was  suffering  from 

is  well  settled  that  persons  who  are  not  sni  juris,  and  have  no  general  capacity  to- 
contract  debts,  are  nevertheless  liable  for  their  torts,  and  may  bind  themselves  for 
necessaries."  The  bank  having  acted  in  good  faith  and  without  notice,  the  estate  of 
Moore  was  liable. 

Mutual  Life  Lis  Co.  vs.  Hunt,  79  N.Y.  541.  Action  for  foreclosure  of  a  mortgage- 
executed  by  defendant  April  23,  1870,  for  $40U0  money  loaned,  payable  September  1, 
1871.  Interest  was  paid  to  March,  1871,  but  in  September,  1871,  default  was  made. 
In  December,  1871,  defendant  was  adjudged  a  lunatic.  At  Special  Term  judgment 
was  gi'anted  for  plaintiffs,  wliich  was  affirmed  at  General  Term  (14  Hun,  169).  The 
Court  of  Appeals  sustained  tlie  judgment,  holding  that  the  fact  that  defendant  was 
declared  insane  after  tlie  mortgage  was  executed  cannot  prevent  plaintiffs  from  enforc- 
ing the  contract,  which  was  made  in  good  faith  by  them,  and  without  notice  or  fraud 
on  their  part. 


IXSAXITV  IX  ITS  MEDICO-LEG JL   IJEAIilXGS.  133 

loss  <»f  im'morv  and  other  mental  symptoms,  and  that  he  was  liable  to 
another  atta<'k,  and  tliat  anj'  exeitement  would  increase  the  tendency  to 
sncli  attaek,  but  would  not  say  that  he  mig-ht  not  marry  without  imperil- 
ing his  life.  The  jury  rt'turn<'d  a  verdict  for  the  i)laintiff  of  £300  damages 
and  costs.  The  ground  of  this  verdict,  it  is  said,  was  that  the  jury  con- 
sidered that  an  unreasonal^le  time  had  elapsed  between  the  date  of  the 
promise  of  marriage  and  the  date  of  the  last  attaek  of  apoplexy. 


Divorce,  Annulment,  Legitimacy,  and  Insanity. 

The  plea  of  insanity  is  sometimes  nrged  as  a  gi'ound  of  divorce,  and  in 
one  case  which  occurs  to  the  writer  the  husband  of  an  insane  woman, 
whose  disease  developed  after  marriage,  brought  suit  for  separation.  In 
ordinary  cases  such  inhumanity,  in  disregarding  the  existence  of  the  af- 
fection as  an  unfortunate  calamity  for  which  the  jjatient  is  no  more  re- 
sponsible than  she  wonld  be  for  smallpox  or  typhoid  fever,  rarel}'  finds 
favor  in  the  eyes  of  the  law;  but  it  can  be  realized  that  in  instances 
when  insanity  has  existed  before  marriage,  and  when  the  husband  or 
Avife  has  been  kept  in  ignorance  of  the  fact  b}'  the  patient,  or  by  his  or 
her  parents  or  near  relatives,  a  delicate  legal  point  may  arise.* 

The  attitude  of  the  German  coiu-ts  regarding  this  question  is  most 
moderate.  A  late  decision  of  the  Beichsgericht  (vol.  xx\di.,  p.  158)  con- 
cerns a  petition  for  the  annulment  of  a  marriage  because  the  husband 
had  an  erroneous  opinion  in  regard  to  the  sanity  of  his  wife  when  mar- 
rying her.  Evidence  was  brought  to  show  that  the  defendant  had  a  he- 
reditary predisj^osition  and  had  been  temporarily  insane  before  as  well 
as  after  her  marriage.  •  The  plaintiff  had  married  the  defendant  in  1886, 
and  after  the  birth  of  a  healthy  child  in  1887  he  left  her,  and  in  1889 
brought  an  action  for  divorce,  alleging  that  his  wife  was  the  subject  of 
liereditaiy  insanity,  and  that  she  had  before  marriage  and  afterward 
shown  signs  of  what  he  claimed  to  be  incurable  insanity,  and  that  he 
was  unaware  of  this  fact  when  he  married  her.  The  defendant  only 
admitted  that  she  had  been  temporarily  deranged  after  the  bii'th  of  her 
child,  such  insanity  being  puerperal,  and,  moreover,  that  the  plaintiff 

*  Banker  vs.  Banlcr,  63  X.  Y.  409.  The  defendant,  Ellen  M.  Banker,  and  John 
Banker  were  married  March  S,  1869.  In  Febrnary,  1869,  proceedings  de  lunatico  in- 
qiiircudo  were  instituted,  and  on  Marcli  10th,  two  days  after  the  marriage,  it  was  found 
that  John  Banker  was  a  lunatic,  and  had  been  for  six  months  previous.  Mrs.  Banker 
liad  notice  of  these  proceedings.  John  Banker  subsequently  died,  and  David  A. 
Banker,  as  heir  at  law,  brought  this  action  for  annulment  of  the  marriage,  on  the 
ground  that  John  was  a  lunatic  at  the  time  the  marriage  was  contracted.  The  jury 
found  that  .John  Banker  was  not  insane  on  March  8,  1869 ;  that  he  had  lucid  intervals, 
and  affirmed  his  marriage  after  that  date;  that  he  was  not  insane  at  the  time  of  his 
death ;  and  that  ^Irs.  Banker  had  notice  of  the  lunacy  proceedings.  Judgment  was 
then  entered  dismissing  tlie  complaint,  which  the  General  Term  affirmed.  The  Coiu't 
of  Appeals  also  affirmed  the  judgment,  "the  inquisition  is  conclusive  against  subse- 
quent acts  and  dealings,  and  presumptive  against  prior  ones,"  irrespective  of  notice. 

Ilairdon  vs.  Rawdon,  28  Ala.  565.  This  was  a  bill  filed  by  ilrs.  Elizabeth  Eawdou 
for  a  divorce  from  her  husband,  Isaac  Kawdon.  It  was  alleged  and  proved  that  they 
were  married;  tliat  Isaac  was  insane  at  the  time  of  marriage,  and  for  some  time  after- 
ward, unknown  to  his  wife.  His  insanity  was  caused  by  bi-ain-fever.  About  the  time 
of  the  marriage  he  had  a  lucid  interval,  but  after  the  marriage  she  began  to  notice  Iiis 
strange  conduct,  althougli  he  was  considered  an  intelligent  man  by  many.  About  six 
years  after  marriage  he  developed  religious  uiauia,  and  his  lucid  intervals  ceased  en- 


134  A   SYSTEM  OF  LEGAL  MEDICIXE. 

had  lieen  aware  of  her  state  of  mind  from  lier  very  yontli.  The  fact 
that  the  brother  of  the  defendant  had  j^assed  two  years  in  a  State  kma- 
tic  asylum  in  1882  and  had  been  discharged  imcured  was  admitted. 
The  court  decided  against  the  plaintiff  on  the  following  grounds :  That 
after  its  investigation,  as  well  as  upon  the  medical  rej^ort'of  the  director 
of  the  asylum,  it  was  clear  that  the  defendant,  at  the  time  of  the  set- 
tlement of  her  maiTiage,  was  not  in  a  state  of  chronic  mental  disease, 
nor  was  she  then  suffering  from  even  a  temporary  attack  of  mental  dis- 
turbance. It  was  determined  that  she  was  hereditarily  afflicted  and  was 
thereby  exposed  to  the  danger  of  mental  disease,  and'  that  twice  in  her 
life,  once  before  her  marriage,  at  the  occasion  of  the  death  of  her  sister, 
and  again  about  six  months  after  her  accouchement,  she  had  suffered 
from  attacks  of  acute  mental  distm-bance  in  the  form  of  passive  melan- 
choha.  It  was  the  opinion  of  the  coui-t  that  no  one  had  ever  gone  so 
far  as  to  decide  that  a  temporary  disturbance  of  mind  which  was  un- 
known to  the  other  party,  occmiing  before  maniage,  even  if  tliis  disturb- 
ance reapi)eared  after  maniage,  could  serve  as  a  cause  for  annulment, 
and,  moreover,  he  was  unaware  of  any  precedent  for  the  annulment  of  a 
marriage  because  one  of  the  contracting  parties  was  hereditarily  aflicted 
with  a  predisi^osition,  and  a  temporary  derangement  had  appeared  after 
the  consummation  of  maniage,  such  disorder  being  provoked  by  suffi- 
cient causes.  In  the  case  under  consideration  the  defendant  recovered 
completely  each  time  after  a  few  weeks.  It  was  also  held  that  the  de- 
fendant had  no  reason  or  cause,  nor  was  she  obliged  in  any  way,  to  com- 
municate to  the  plaiutiff  the  fact  or  natm-e  of  her  previous  iUness. 

It  has  also  been  held  by  the  German  com-ts  that  an  innocently  ac- 
quired insanity  of  husband  or  wife  does  not  constitute  sufficient  ground 
for  divorce.  {ITjid.,  vol.  vii.,  p.  154.)  The  com-ts  even  go  so  far  as  to  protect 
the  insane  defendant  whose  disease  prevents  the  consummation  of  cer- 
tain customary  habits  of  matrimony  (sexual  iutercoiu'se,  etc.).  The  AU- 
germine  Protestardisdte  Kirchen-Eecht  (General  Protestant  Church  Law) 
considers  wedlock  as  a  communion  standing  above  a  common  agi'eement 
and  bindiag  the  whole  personahty  of  the  contracting  parties  in  ah  situa- 

tirelr.  During  Ms  paroxysms  lie  frequently  attempted  to  kill  his  negi-oes,  and  actually 
did  kill  their  only  child,  erected  a  scaffold,  and  bm-ned  the  body,  saying  that  he  "  offered 
his  son  a  sacrifice  to  God,  as  Abraham  had  offered  his  son  Isaac  " ;  and  he  had  since 
been  confined  in  an  asylum.  The  bill  -was  dismissed  on  the  gi'ound  that  the  marriage 
was  contracted  during  a  lucid  interval ;  and  on  appeal  the  Supreme  Court  affirmed  this 
judgment  on  the  gi'ounds  named  above.  The  com-t  also  laid  stress  on  the  facts  that 
the  marriage  was  contracted  in  1826,  in  1836  Eawdon  developed  insanity,  and  Mrs. 
Kawdon  did  not  file  her  bill  imtil  1854. 

State  ex  rel  Setzer  vs.  Setter,  97  N.  C.  252.  In  August,  1859,  Eeuben  Setzer  and 
Sophronia  Morcus  were  married,  and  lived  together  until  1862,  when  he  enlisted  in 
the  Confederate  army  and  was  killed.  This  action  was  brought  by  the  State  on  the 
relation  of  Jacob  C.  Setzer,  the  only  child  born  of  the  marriage,  against  the  defend- 
ant, who  administered  the  estate  of  Reuben  Setzer  on  his  bond  for  a  share  of  the 
personal  e.state.  The  defense  was  that  Eeuben  had  been  an  imbecile  fi-om  his  youth 
up,  and  was  insane  at  the  time  the  marriage  was  contracted.  A  jury  declared  that  the 
inte.state  did  not  have  mental  capacity  to  contract  the  mamage,  and  judgment  was 
rendered  for  defendant,  which  on  appeal  was  reversed  by  the  Supreme  Court,  the  court 
holding  that  the  question  of  the  validity  of  a  mamage  could  not  be  considered  in  an 
action  by  children  of  the  marriage  claiming  as  next  of  kin,  neither  of  the  parties  to 
the  marriage  being  before  the  court,  and  that  "  the  present  verdict  cannot  take  from 
the  relator  any  of  his  rights  as  a  son  of  the  intestate  to  a  share  in  the  latter's  estate, 
nor  render  his  birth  illegitimate." 


JXSAmTY  IX  ITS  MEDICO-LEGAL   nEJUlXGS.  135 

tions  and  possibilities  of  life  until  one  or  the  other  of  the  parties  be- 
<,'onics  by  his  own  fuult  unworthy  of  the  other.  Unconsciously  ac(|uire(l 
madness,  if  developed  after  inarriag'e,  is  therefore  no  ground  for  divorce. 
The  Gernuiu  law  [Alh/ciiwiiics  Ijoidrerht,  sec.  G982),  however,  holds  that 
rage,  insane  fury,  and  dangerous  madness  justify  a  divorce  when  such 
a  derangement  has  lasted  for  more  than  a  year  and  there  is  no  possible 
lK)pe  of  recovery. 

The  famous  Mordaunt  Divorce  Case,  in  which  the  Prince  of  Wales  fig- 
ured, is  one  in  which  j^uerjDeral  insanity  was  urged  as  the  basis  of  irrespon- 
sibility. Lady  Mordaunt,  after  her  confinement,  admitted  that  she  had  com- 
mitted adultery  before  the  birth  of  her  child,  and  the  evidence  substanti- 
ating her  story  was  seemingly  ver}-  strong,  for  entries  in  her  diary  a  year 
before  recorded  the  visits  of  a  nobleman  at  an  hour  of  the  iiiglit  inconsist- 
ent with  the  strictest  propriety.  This  occurred  two  hundred  and  eighty 
days  before  the  birth  of  her  child.  It  appeared  from  the  testimony  of 
servants  and  others  that  there  had  been  no  signs  of  anything  pecidiar 
in  the  conduct  of  Lady  Mordaunt  either  before  or  after  her  delivery, 
and  this  was  in  contradiction  of  those  friends  of  the  patient  herself 
who  asserted  that  her  confession  was  the  result  of  a  delusion ;  for  not 
only  had  the  wife  admitted  improper  relations  "s^dth  other  men,  but  swore 
that  the  child  was  not  her  husl^and's.  The  patient  was  delivered  of  her 
child  on  the  28th  of  February,  1869,  and  a  week  or  two  later  made 
her  extraordinary  admission.  The  physicians  called  by  the  plaintiff 
were  inclined  to  think  that  she  was  not  insane,  and  that  there  was 
nothing  in  her  conduct  inconsistent  with  feigning.  The  reasons  assigned 
as  evidences  of  her  insanity  were  of  the  most  extraordinary^  description, 
but  they  were  met  with  much  that  was  contradictory.  It  was  shown 
that  her  habits  had  become  filthy,  that  she  destroj^ed  her  clothing  and 
was  unclean  in  her  habits ;  and  in  1870  she  was  demented  and  could  not 
comprehend  communications  that  were  made  to  her.  The  jury  and  the 
judge  took  this  latter  view  of  the  case,  aud  it  was  decided  that  as  early 
as  the  30th  of  April  the  respondent  had  not  sufficient  capacity  to  bring 
the  suit,  and  had  been  unfit  ever  since.  The  charge  of  the  judge  to  the 
jury  was,  that  he  did  not  ask  them  to  say  whether  Lady  Mordaunt  was 
sane  or  insane,  but  simply  to  decide  ''  whether  she  was  or  not  in  such  a 
state  of  mental  disorder  as  to  jn-event  her  giving  instructions."  The  ease 
was  afterward  appealed  and  tried  upon  its  merits,  the  matter  of  insanity 
being  left  out  of  the  question,  the  defendant  being  considered  guilty  of 
adidtery,  and  the  divorce  was  granted.  Woodman  and  Tidy,  in  com- 
menting upon  this  case,  say :  ''  It  is  thus  seen  that  insanity  is  no  bar  to  a 
decree  of  divorce — a  principle  which  seems  to  us  far  from  being  a  safe 
one.  In  a  case  of  miu'der  the  evidence  of  other  persons  or  circumstantial 
evidence  may  be  sufficient.  In  the  relations  of  husband  and  wife  it  seems 
hard  to  punish  the  wife  while  she  is  unable  to  defend  herself.  At  all 
■events,  if  the  principle  be  admitted,  it  seems  unjust  that  a  poor  laborer 
should  have  to  pay  toward  the  support  of  an  insane  "wife  in  Colney 
Hatch  or  Hanwell,  and  l)e  liable  to  a  prosecution  for  bignmy  if  he  mar- 
ries again,  while  the  wealthy  baronet  escapes  almost  scot-free  and  may 
marry  again  if  he  choose." 

Marriages  contracted  in  exfre)nis  are  usually  very  apt  to  be  dissolved 
l)v  courts  of  law.  Tidy  refers  to  the  case  of  Rochefort,  who  was  married 
to  his  former  mistress  on  her  death-bed,  he  being  taken  from  prison  for 


136  ^   SYSTJEM  OF  LEGAL  MEDICINE., 

the  purpose.  It  appeared  that  the  woman  was  iu  her  right  mind,  and 
consequently  the  marriage  was  held  to  be  valid.  But  where  one  of  the 
parties  is  overawed,  or  there  is  any  evidence  of  mental  perversion,  the 
legality  of  the  contract  is  properly  questioned. 

A  case  showing  that  the  alleged  insanity  must  be  that  which  iu  itself 
wiU  interfere  with  a  proper  understanding  of  the  marriage  contract  is 
the  following.      In  it  "  kleptomania  "  was  urged  as  a  ground  for  divorce. 

Lewis  vs.  Leivis,  44  Minn.  124.  The  parties  to  this  action  were  mar- 
ried in  1882,  At  the  time  the  defendant  was  insane,  but  this  fact  was. 
concealed  from  plaintiff  until  1888.  The  plaintiff  brought  suit  to  annul 
the  marriage  on  the  ground  of  fraud  in  the  concealment  of  defendant'^ 
insanity,  and  also  that  defendant  was  not  competent  to  enter  into  a  mar- 
riage contract.  The  insanity  alleged  was  "  a  morbid  propensity  on  the 
part  of  the  wife  to  steal,  commonly  denominated  '  kleptomania.' "  Judg- 
ment for  defendant,  which  was  affirmed  by  the  Supreme  Coui"t,  on  the 
ground  that  the  insanity  proved  did  not  show  that  defendant  was  in- 
capable of  understanding  the  marriage  contract,  and  that  the  conceal- 
ment practiced  was  not  sufficient  to  justify  the  court  in  annulhng  the 
marriage. 

The  plea  of  non-support  by  reason  of  insanity  as  a  ground  for  divorce 
has  not  found  favor  with  the  conrts.*  In  the  case  of  BaAer  vs.  Baker,  82 
Indiana  Reports,  146,  it  was  shown  that  plaintiff  and  defendant  were 
married  in  1867.  In  1874  defendant  became  insane,  and  was  committed 
to  an  asylum,  where  he  has  since  remained.  Plaintiff  instituted  this  suit 
for  a  divorce  on  the  ground  that  defendant  failed  to  support  her.  The 
Supreme  Court  on  appeal  held  that  this  did  not  constitute  sufficient 
ground  for  divorce;  that  the  statute  providing  for  divorce  where  the 
husband  fails  to  support  his  wife  does  not  apj)ly  when  such  failure  is 
caused  by  mental  or  ph3;^sical  disease. 

Another  issue  was  raised  in  the  case  of  Gevliold  vs.  TFyss,  12  North- 
western Reporter,  800.  The  plaintiff  and  defendant  were  married  in 
"  September  or  October,  1867."  A  few  days  thereafter  plaintiff  learned 
of  defendant's  insauitj^,  but  continued  to  li-^^e  with  her  until  September, 
1881,  when  a  decree  of  separation  was  made.  He  now  sues  for  her  sup- 
port during  the  tune  they  lived  together.  The  Supreme  Court  of  Ne- 
braska held  that  as  plaintiff  knew  of  defendant's  insanity,  but  continued 
to  live  "with  her,  he  was  obliged  to  support  her. 

The  existence  of  epileptic  insanity  or  epilepsy  may  form  the  basis  of 
legal  proceedings,  and  the  existence  of  epilepsy  which  has  been  concealed 
by  the  subject  from  the  other  contracting  party  may  arise  in  proceedings 
for  divorce.  A  pertinent  case  is  related  by  Trousseau  of  a  lady  who  was 
aroused  at  night  by  the  restlessness  of  her  husband,  who  violently  at- 
tacked her,  and  she  was  obliged  to  call  for  assistance.  This  occurred 
again,  and  by  means  of  a  light  she  was  enabled  to  see  the  patient  in  the 

"*  Bell  vs.  Bennett,  73  Ga.  784.  This  was  an  action  by  Mrs.  Bennett  against  the 
administrator  of  Jesse  Bennett  for  a  year's  support,  Mrs.  Bennett  chiiming  to  be  the 
■wife  of  Jesse.  Tlie  defense  was  that  at  the  time  of  the  pretended  marriage  Jesse  was 
insane,  and  that  slie  lived  with  him  but  a  short  time  and  then  eloped  with  another  man, 
with  whom  she  lived  for  twelve  years  ;  biit  the  Trial  Court  refused  to  receive  e^adenee 
in  support  of  these  facts,  and  ordered  judgment  for  Mrs.  Bennett.  On  appeal  the  Su- 
preme Court  held  that  Bennett  was  insane  at  the  time  of  the  marriage,  which  w^as,, 
therefore,  void,  and  remained  void  till  his  death,  and  reversed  the  judgment. 


lySJNITY  IX  IIS  MEDICO-LEGAL   BEAIilXGS.  137 

midst  of  a  severe  epileptic  attack,  and  he  would  again  have  done  violence 
if  not  restrained.  In  this  ease  the  patient  had  but  an  indistinct  idea 
afterward  of  his  condition,  but  he  admitted  having  had  other  attacks 
previous  to  his  marriage,  of  a  vertiginous  character.  Hence  it  seems  to 
me  there  should  be  no  reasonable  excuse  for  denying  a  divorce,  especially 
if  the  patient  was  cognizant  of  liis  previous  disease  and  neglected  to 
communicate  his  knowledge  to  his  wife. 


BANKRUPTCY. 

A  person  who  in  the  eyes  of  the  law  is  non  compos  mentis  cannot  com- 
mit an  act  of  bankruptcy  while  his  disability  lasts,  but  if  he  has  done  so 
previous  to  his  lunacy,  he  may  be  made  the  subject  of  a  commission  of 
bankruptcy.*  (Ordronaux.)  He  cannot  be  arrested,  and  during  the 
continuance  of  his  insanity  the  time  cannot  be  regarded  as  a  part  of  that 
limited  for  certain  motions  to  set  aside  a  judgment. 


THE   INSANE  AS  WITNESSES. 

The  testimony  of  a  lunatic  whose  incapacity  has  been  determined  is 
of  course  incompetent,  and  he  will  not  be  permitted  to  testify  until  after 
his  restoration  to  mental  health.  The  time  of  existence  of  his  "civil 
death  "  is  to  be  determined  before  any  testimony  shall  be  received.  "  Look- 
ing at  the  condition  of  the  mental  faculties  during  the  prevalence  of  in- 
sanity, the  disturbance  of  their  equipoise,  the  emotional  excitability 
present,  and  the  underlying  raptus  mamacus  touching  every  faculty  at 
some  point ;  rememljering  also  that  every  human  being  is  steeped  in 
his  own  temperament,  wears  the  liver}^  of  his  ordinary  mental  states,  and 
exhibits  in  his  unguarded  acts  the  complexion  of  his  predominant  moral 
feelings — we  are  forced  to  the  conclusion  that,  even  outside  of  the  sphere 
of  delirium  and  incoherence,  the  statements  of  one  who  is  insane  or  has 
been  profoundly  so,  but  is  now  recovered,  need  to  be  scrutinized  from 

"  Stock.  N.  C.  38. 

In  re  Murphy,  10  National  Bankruptcy  Reg.  48.  A  petition  in  bankruptcy  was 
filed  against  Alonzo  Murphy  by  his  creditors,  and  on  his  failiu*e  to  answer  he  was  ad- 
juged  a  bankrupt  by  default,  and  his  property  was  turned  over  to  the  assignee.  Be- 
fore distribution  had  been  made  Murphy  appeared  with  an  application  alleging  that 
he  was  iio)i  contpos  mentis  at  the  time  the  debts  were  created  and  the  bankruptcy  pro- 
ceedings instituted,  and  the  court  (United  States  District  Court,  Tennessee)  opened 
the  default.  Subsequently  a  jiu-y  rendered  a  verdict  of  insanity,  and  the  assignee  was 
ordered  to  return  the  property  to  Murphy. 

Ih  re  Weitzel,  7  Bisscll,  289.  This  was  an  involuntary  petition  in  bankruptcy. 
Insanity  of  bankrupt  was  pleaded  as  a  defense.  On  demurrer  to  the  answer  the  United 
States  District  Court  for  the  Western  District  of  Wisconsin  decided :  First,  That  a 
lunatic  can  be  adjudged  a  bankrupt  against  the  consent  of  his  guardian.  Second, 
Tliat  an  insane  person  cannot  commit  an  act  of  bankruptcy. 

Ill  re  Marvin,  1  Dillon,  178.  William  L.  ^[arvin,  a  merchant,  siispended  payment 
on  January  -i,  1871,  and  did  not  thereafter  resume,  and  his  property  was  levied  on 
shortly  afterward.  In  February  this  petition  in  bankruj-ttcy  was  filed  against  Mar- 
vin, who,  by  his  guardian,  answered  that  on  January  30.  1871.  he  had  been  adjudged 
insane,  and  that  he  was  insane  at  the  time  the  acts  of  bankruptcy  were  committed. 
Tlie  District  Court  overruled  a  demurrer  to  the  answer,  aiul  on  appeal  tlu^  Circuit 
Court  affirmed  the  judgment,  holding  that  a  person  who  is  "wholly  incapable"  can- 
not commit  an  act  of  bankruptcy. 


138  ^    SYSTEM    OF  LEGAL  MEDICINE. 

a  standpoint  not  so  mncli  of  veracity  as  of  intellectual  competency." 
(Ordronanx.)  Authentic  instances  of  a  lunatic  testifjdng  are  rare.  In 
the  case  of  Begina  vs.  Hill,  2  Denis,  C.  C,  254, 1851,  a  lunatic,  Donnelly, 
was  permitted  to  testify  in  regard  to  an  assault  after  having  been  ex- 
amined as  to  his  competency.  Although  exceptions  were  taken,  the  ver- 
dict was  sustained. 

As  to  matters  of  bare  fact  thei-e  can  be  no  doubt  that  an  insane  per- 
son is  often  able  to  testify  intelligently,  but  it  is  necessan'  to  ascertain 
if  a  delusion  or  delusions  exist,  or  if  the  person  called  entertains  insane 
prejudice.  In  matters  where  the  slightest  question  of  opinion  or  the 
formation  of  an  opinion  arises,  the  testimony  of  such  a  person  should 
be  accepted  with,  the  greatest  care,  especially  in  cases  where  emotional 
states  exist.  Some  authors  hold  that  a  person  who  has  been  insane  and 
recovered  should  be  permitted  to  testify  to  facts  occurring  during  his 
insanity,  provided  the  facts  are  "  objectively  demonstrable,"  and  he  knows 
the  nature  of  an  oath,  and  the  court  is  satisfied  with  his  degree  of  under- 
standing; but  that  "a  personal  and  self -regarding  incident  occurring 
during  a  period  of  insanity,  and  testified  to  by  its  subject  either  while 
still  insane  or  when  recovered  from  that  state,  should  not  be  treated 
per  se  as  an  evidential  fact."  On  the  whole  his  testimony  should  be  cor- 
roborated, 

THE   COMMITMENT  OF   THE  INSANE. 

The  laws  governing  the  commitment  of  the  insane  vary  greatly  in 
detail.  (See  Appendix.)  In  some  States  the  affidavit  of  one  physician 
is  sufficient,  in  others  two,  while  in  others  the  alleged  lunatic  is  to  be 
brought  before  a  jury,  who  pass  upon  his  case. 

The  appointment  of  a  commission  is  a  more  elaborate  and  satisfactory 
way  of  determining  the  incapacity  of  a  person,  if  he  be  a  lunatic  or 
habitual  drunkard ;  and  the  duty  of  such  a  body  is  to  fix  his  status  so 
far  as  his  being  a  free  agent  is  concerned,  to  inquire  whether  or  not  he 
is  able  to  manage  his  property,  and,  if  necessary,  to  appoint  a  guardian 
of  his  estate  and  person.  Upon  the  presentation  of  a  petition  a  judge 
of  a  court  of  record  usually  appoints  three  persons,  one  of  whom  is  a 
physician,  and  another  a  lawyer,  and  these  conduct  a  hearing  either  in 
the  presence  of  a  sheriff's  jury  (New  York)  or  a  specially  impaneled  jury. 
Upon  the  finding  of  this  body  that  the  person  is  insane  and  unable 
to  manage  his  property  or  himself,  a  proper  guardian  or  guardians  are 
appointed ;  sometimes  one  for  the  care  of  the  property,  and  another  for 
the  person.  If  the  patient  demurs  at  the  finding  he  has  the  right  to  a 
traverse,  which  is  granted  if  the  appointing  judge  deems  it  wise,  in  view 
of  his  condition — that  is,  whether  his  will  is  not  entirely  gone  or  there 
is  a  possible  doubt — when  an  appeal  is  permitted  to  a  court  and  jury,  who 
decide  whether  or  not  his  denial  of  the  charge  of  insanit}^  is  well  founded. 

The  fullest  inquiry  should  be  made  in  such  cases,  although  reform  is 
needed  in  the  adnussion  of  testimony.  In  its  efforts  to  protect  the  indi- 
vidual, justice  sometimes  topples  backward ;  and  in  its  granting  of  lati- 
tude in  the  application  of  legal  rules,  hearsay  and  prejudiced  testimony 
are  admitted,  some  of  which,  even  if  subsequently  discarded,  infiuences 
the  mind  of  the  too  sj-mpathetic  jurymaii.  Great  care  should  be  taken 
in  giving  or  preparing  testimou}-,  for  it  often  happens  that  the  reasons 


JXS jy J TY  ly  ITS  MEDlCU-LEdAL   nEARlMJS.  I39 

assigned  for  the  alleged  iu.siuiity  are  of  the  most  flimsy  character,  and 
may  be  trumi)ed  \\\)  by  designing  relatives  and  too  readily  accepted  by 
careless  medical  men.  It  shonld  be  asc(?rtained  whether  the  individual 
has  been  insanelu  extravagant ;  or  whether  he  has  been  swindled  repeat- 
edly or  drawn  into  absm-d  spi^culations.  One  old  lady  whom  I  examined 
invested  two  thirds  of  her  small  fortune  in  bogus  mining  companies 
within  a  few  months,  and  spent  considerable  suras  of  money  in  the  most 
foolish  ways,  while  before  this  time  she  was  penurious  and  economical. 
It  is  often  necessary  to  decide  the  question  whether  a  person  of  weak 
mind  shoidd  be  detained  in  an  asylum  or  placed  in  charge  of  a  guardian 
and  permitted  to  live  outside ;  and  the  courts  are  exceedingly  lenient  in 
such  matters  and  justly  so,  being  especially  careful  in  regard  to  the  pos- 
sible abridgment  of  personal  liberty.  The  Dickie  Case  was  one  of  this 
kind,  and  though  the  medical  men  who  examined  the  patient  considered 
her  an  insane  person,  their  view  of  the  case  was  disregarded,  and  the 
late  Judge  Brady  ordered  Miss  Dickie's  discharge,  but  appointed  a 
guardian. 

"  Miss  Dickie  was  sent  to  Bloomingdale  on  the  certificates  of  Dr. 
White,  and  of  Dr.  Alfred  C.  Post.  She  was  accepted  as  a  lunatic  by  Dr. 
Tilden  Brown,  and  retained  as  such  by  Drs.  Nicholl  and  McDonald,  with 
the  implied  consent  of  her  aged  and  imbecile  father's  physician  and 
guardian,  Dr.  Rauney. 

'■'■  On  the  afternoon  of  January  16, 1878,  Miss  Dickie  was  visited  by  a 
physician,  who  gave  her  his  name  and  address,  and  told  her  he  was  a 
physician  who  had  come  to  see  her.  She  was  found  to  be  diminutive  in 
size,  lame,  and  api^arently  deformed,  hard  of  hearing,  and  with  speech 
very  indistinct  and  imperfect,  from  a  very  wretched  condition  of  her 
gums,  teeth,  and  mouth.  The  latter,  it  was  supposed,  could  easily  have 
been  relieved  by  careful  rinsing  and  washing  of  the  mouth.  There  were 
other  signs  of  carelessness  of  person  and  dress  which  were  not  ^dsible  in 
the  persons  of  the  matron,  attendants,  and  other  patients  who  were 
casually  observed. 

"  In  a  little  while  she  was  conversing  quite  freely  about  bad  treat- 
ment she  had  received  from  her  father,  who,  she  said,  used  to  puU  her 
hair  and  otherwise  maltreat  her ;  of  deceit  on  the  part  of  her  brother  and 
sisters ;  of  bad  treatment  on  the  part  of  Dr.  Brown  and  others.  She  also 
complained  of  the  food  she  received ;  that  they  sometimes  had  onions  for 
dinner,  and  that  these  were  served  especially  to  annoy  her.  She  stated 
that  an  effort  was  being  made,  with  her  consent  and  that  of  her  family, 
to  remove  her  from  the  asylum,  and  expressed  a  preference  to  live  in  the 
city  rather  than  in  the  (jountry,  with  some  slight  hint  which  suggested 
that  she  did  not  like  green  things,  but  desired  to  visit  shops,  go  ro  her 
own  church,  give  money  to  it,  and  live  by  herself.  She  volunteered  to 
say  that  she  read  the  l:imi  and  the  Ohserver,  and  showed  copies  of  them ; 
that  she  had  a  great  impulse  to  improve  her  mind ;  quoted  some  simple 
little  nuixims  at  times,  especially  about  not  talking  too  much,  when  she 
was  monoi)olizing  almost  the  whole  conversation.  As  she  occasionally 
quoted  Scripture,  she  was  asked  if  she  had  a  Bible ;  it  was  then  noticed 
that  she  seemed  to  keep  almost  all  her  property  under  lock  and  key,  but 
she  quickly  produced  her  Bible  from  a  locked  drawer,  and  it  was  found 
not  only  filled  with  pencil-marks  from  Genesis  to  Revelation,  but  many 
pages  were  folded  in  the  most  curious  and  complicated  ways,  as  if  to 


140  ^   SYSTEM  OF  LEGAL  MEDICLyE. 

mark  special  j^assages  of  great  import  to  herself :  but  her  \'isitor  was 
siu'prised  on  unfolding  these  ciuionsly  donbled-up  pages  to  find  no 
pencil-marks  Avhatever  upon  some  of  them,  and  she  avoided  answering 
why  she  thus  pointedly  singled  out  particular  pages.  It  is  bareh^  pos- 
sible that  those  were  pages  which  she  did  not  wish  to  read,  but  nothing 
could  be  detected  strikingh^  peculiar  in  the  contents  of  those  pages  upon 
a  short  examination. 

"  Her  fii'st  visitor  had  been  alone  with  her  for  half  an  hour  or  more 
when  another  physician  came  into  the  room,  and  was  introduced  by  name 
and  title  as  a  second  medical  man  who  had  come  to  see  her.  She  imme- 
diately went  on  conversing  with  hun.  His  attention  was  attracted  by 
hearing  her  tell  her  second  visitor  that  there  was  a  language  of  food  as 
well  as  of  flowers,  and  when  asked  for  an  illustration  stated  that  coffee 
was  brown,  brown  was  a  Quaker  color,  a  Quaker  was  a  Friend,  and  that 
hence  coffee  meant  friendship ;  that  if  one  j^erson  gave  another  a  cup  of 
coffee,  it  was  a  sign  of  friendsliip,  and  if  milk,  which  was  white,  was  put 
into  it,  it  was  a  sign  of  j)ure  fi'iendship,  and  the  addition  of  sugar  made 
it  an  indication  of  sweet  friendship — in  short,  that  coffee  with  milk  and 
sugar  in  it  was  indicative  of  pm-e,  sweet  fi-iendship.  Then  she  vohmteered 
to  say  that  bread  represented  a  fiiend ;  that  a  big  piece  of  bread  was  a 
sign  of  a  large  friend ;  that  butter  signified  refinement,  and  bread  and 
butter  a  refined  friend.  She  then  quickly  said  that  cabbage  was  white 
on  the  inside,  and  that  signified  pm-ity,  and  gTeen  on  the  outside ;  but  no 
C[uestioning  could  make  her  say  what  the  green  meant.  She  continued 
to  say  if  one  cut  up  the  inside  of  cabbage  and  put  it  on  a  little  plate,  it 
would  indicate  puiity  and  something  else  which  she  would  not  disclose, 
possibly  because  it  had  reference  to  the  gi'een  color. 

"  Repeatedly,  while  tliis  conversation  was  going  on.  her  visitors  were 
warned  not  to  speak  loud,  as  persons  were  watching  all  the  time,  up- 
stairs and  downstaii-s,  through  the  register,  pipes,  etc.,  presumably  the 
waste,  water,  or  gas  pipes,  none  of  which,  however,  could  be  seen  on 
casual  inspection.  These  persons  were  also  said  to  whisper  to  her 
through  the  tubes.  She  declared  that  this  food  language  was  not 
peculiar  to  herself,  but  was  known  to  and  in  constant'use  by  aU  the 
attendants  and  patients;  that  her  conversation  and  letters  were  com- 
municated or  perhaps  telegraphed  about  the  house,  as  she  inferred,  by  • 
single  words,  said  by  different  persons,  in  various  places,  in  the  midst  of 
theii-  conversation,  and  by  putting  these  detached  words  together  she 
found  out  by  something  in  her  heart  or  chest — not  in  her  head — that 
they  had  become  acquainted  with  the  letters  she  had  T^-i-itten  and  the 
conversations  she  had  had  with  others  and  presumaljly  with  herself. 

'■'•  It  was  very  evident,  said  the  judge,  that  3Iiss  Dickie  was  of  unsound 
and  imperfect  mind  and  understanding,  yet  for  an  houi-  and  a  half  she 
had  given  no  positive  signs  of  absolute  mental  derangement.  She  knew 
who  and  where  she  was,  described  the  institution  as  a  house  of  afiliction. 
but  she  made  no  allusion  or  complaint  of  her  fellow-sufferers,  or  of  any 
noises  or  annoyances  except  the  imaginary  whisperings  through  the 
tiil:»es.  She  was  conscious  of  her  own  weakness  and  ignorance  of  many 
things ;  seemed  satisfied  to  have  as  her  guardian  a  bank  president,  whom 
she  named,  as  she  was  not  accustomed  to  deal  with  large  sums  of  money. 
In  short,  she  presented  the  usual  mixture  of  reason"  and  unreason  so 
common  in  many  simple  lunatics.     Sometimes  she  exhibited  a  good  deal 


IXSANITY  IN  ITS  MEDICO-LEGAL   BEARINGS.  141 

of  tact  and  cunning,  at  other  times  of  extreme  cliildislniess  and  sim- 
plicity, mixed  up  with  delusions,  hallucinations,  unf(junded  suspicions, 
extreme  prejudice  and  hatred,  great  Christian  piety,  charity,  and  benevo- 
lence. 

"  The  only  question  that  coidd  arise  was  whether  it  was  absolutely 
necessary  to  retain  her  in  the  asylum.  There  seemed  no  objection  to  a 
trial  elsewhere,  provided  all  her  property  should  not  pass  into  the  hands 
of  strangers  and  irresponsible  persons ;  that  a  proper  residence  should  be 
selected  where  her  peculiarities  should  not  become  the  sport  of  the  foolish 
and  indiscreet ;  and  that  a  competent  maid,  nurse,  assistant,  or  matron 
could  be  found,  possessed  of  unmeasured  patience,  tact,  and  reso- 
lution." 

This  action  illustrates  the  conflict  that  frequently  arises  in  cases 
where  medical  men  bring  to  their  aid  their  experience  in  other  cases. 
This  patient  was  evidently  a  chronic  delusional  lunatic,  and  although  her 
history  had  been  a  harmless  one  she  evidently  owed  her  improvement  to 
the  care  of  an  asylum,  and  was  not  there  subjected  to  the  disturbing 
irritation  which  she  subsequently  would  have  been  affected  l)y  outside. 
Every  one  is  familiar  with  the  cases  of  so-called  harmless  lunatics  who 
have  been  liberated.  In  many  such  instances  the  removal  of  all  restric- 
tion has  resulted  in  a  train  of  disorderly  conduct,  extravagance,  family 
quarrels  based  upon  delusive  ideas  of  persecution,  foolish  marriages,  and 
insane  wills.  In  such  cases  it  undoubtedly  happens  that  sometimes  the 
patients  may  fall  into  the  hands  of  designing  guardians,  so  that  the  legal 
action  may  prove  rather  a  curse  than  a  blessing. 

The  legal  duty  of  commissions  is  to  prove  the  general  existence  of 
insanity,  and  for  that  reason  the  courts  are  apt  to  ignore  isolated  or 
limited  evidences  unless  they  be  especially  dramatic ;  on  the  other  hand, 
the  desire  to  protect  the  patient  is  such  that  minor  indications  of  es- 
tablished degenerative  insanity  are  disregarded.  For  this  reason  the 
law,  as  will  be  shown  hereafter,  looks  with  suspicion  upon  e^ddences  of 
moral  weakness,  no  matter  how  suggestive  they  may  be  of  mental  dis- 
organization.* 

It  was  held  in  the  case  of  Patterson  (4  How.  Pr.  S-l)  that  the  retro- 
speefire  finding  of  a  jury  regarding  the  acts  of  a  lunatic  or  habitual 
drunkard  is  only  presumptive  and  not  conclusive  evidence  of  incapacity.! 
Ordronaux,J  in  commenting  upon  these  cases  and  that  of  Wadsworfh  vs. 
Sharpsteen  (14  Barb.  169  ;  affirmed  in  8  N.  Y.  388),  where  the  reverse  was 
held,  considers  that  a  possible  lucid  interval  was  overlooked  in  the  latter, 
and  concludes :  "  Legally  considered,  every  form  of  lunacy  inqihes  the 
possibility  of  an  intercurrent  lucid  interval;  and  until  that  possil)ility 
is  judiciall}^  declared  never  to  have  borne  fruit,  the  only  proper  infer- 
ence is  that  it  may  have  done  so ;  and  consequently  that  an  inquisition 
which  overlooks  the  question  of  lucid  intervals  is  only  presunqitive  and 
not  conclusive  evidence  of  past  continuous  incapacity."  {Searles  vs.  Har- 
vey, 6  Hun,  C58.)  The  finding  of  a  commission  that  a  person  is  insane 
is  only  j^rhua  facie  evidence  of  business  incapacity  so  far  as  a  third  per- 
son is  concerned,  nor  are  they  competent  to  dissolve  a  partnership.   This 

*  Titcomh  vs.  Taniyle,  84  111.  371 :  Jacox  vs.  Jacox,  40  Mich.  473  ;  Fcntrus  vs.  Fentnis, 
7Heisk  (Tenn.),  428;  etc. 

t  Van  Dciifioi  vs.  Sweet,  51  N.  Y.  378. 

t  Mcdiccd  JurisprHdence  of  Insanitij,  ji.  247. 


142  ^   SYSTEM  OF  LEGAL  MEDLCLNE. 

must  be  determined  by  a  jndge,  who  takes  into  account  all  tlie  features 
of  the  case,  the  degree  of  the  unsoimdness,  and  whether  it  is  recover- 
able. 

tra^t:rse. 

If  it  is  desu-ed  to  traverse  the  finding  of  a  commission,  the  lunatic^ 
his  friends,  or  any  one  legally  empowered  to  act  may  make  apphcation. 
This  includes  those  who  may  have  had  contracts  with  hiin,  or  who  have 
been  or  are  likely  to  suffer  by  his  acts*  The  court  will  protect  the  in- 
terests of  the  lunatic  during  the  pending  of  the  proceedings.t  Apphca- 
tion for  a  traverse  should  be  accompanied  by  affidavits  and  the  service 
of  papers  upon  the  op^Dosiiig  counsel. 

Suits  may  be  brought  in  behalf  of  the  committee  of  estate ;  but  should 
the  complainant  himself  be  a  lunatic,  the  defendant  may  demur  when  it 
is  the  custom  to  appoint  a  guardian  to  aj)pear  in  his  behalf.  According 
to  section  375  of  the  new  Code  of  Civil  Procedure,  the  limit  of  time  in 
which  a  lunatic  may  bring  action  to  recover  real  propertj^,  or  enter  a 
defense  or  coimter-claim  founded  on  the  title  of  real  property  or  the 
income  therefrom,  "is  not  a  part  of  the  time  limited  in  that  title  (twenty 
years — sections  365,  366),  except  that  the  time  so  limited  cannot  be  ex- 
tended more  than  ten  years  after  the  disabihty  ceases."     (Ordornaux.) 

In  the  case  of  BaJier  vs.  Balier,^  where  an  action  for  divorce  was 
brought  against  the  lunatic's  wife,  it  was  held  that  the  committee  of  the 
estate  and  not  the  committee  of  the  person  should  bring  the  suit.  In 
the  committee  of  the  person  or  estate  is  vested  the  right  to  defend  or 
bring  suit  whenever  it  may  be  necessary  to  question  or  stand  by  the 
contracts  of  his  charge  before  the  deprivation  of  civil  rights.§ 

A  lunatic  cannot  be  restrained  unless  he  is  dangerous  to  himself  or 
to  the  community  becaiise  of  his  violent  acts,  or  that  he  may  wander 
about  and  get  into  harm's  way.  To  specify  these  would  be  to  go  over 
much  of  the  ground  we  have  ti-aversed.  It  is  clearly  proper  to  send  such 
a  person  to  an  asylum  for  treatment  when  the  facilities  for  it  elsewhere 
are  inadequate ;  and  in  the  hght  of  skilled  experience,  isolation  is  deemed 
an  early  and  important  requu-ement  in  most  forms  of  insanity.  Various 
authorities  insist  upon  the  fact  that  because  a  person  is  a  fit  subject  for 
an  inquisition,  it  does  not  foUow  that  he  is  to  be  incarcerated. 

The  apprehension  or  removal  of  a  patient  from  one  State  to  another 
for  the  purjjose  of  avoiding  legal  or  other  consequences  may  be  thwarted 
by  the  application  for  a  commission ;  in  fact,  persons  who  have  so  spirited 
lunatics  away  have  been  obhged  to  return  them.  (Wykeham,  1  Tm-n. 
&  Russ.  587.) 

*  Christie,  5  Paige,  242  ;  Giles,  11  Paige,  243  ;  Hale,  7  Ves.  261 ;  Roberts,  3  Atk.  308. 

t  WendeU,  1  Johns.  Ch.  600 ;  Russell,  1  Barb.  Ch.  42. 

i  L.  R.  5  P.  D.  145. 

^  Carter  vs.  Bechicitli,  128  N.  Y.  312.  In  1855  defendant's  intestate  was  adjudged 
a  lunatic,  and  a  commission  issued.  In  1871  the  plaintiff,  an  attorney,  instituted  pro- 
ceedings in  his  behalf,  wliich  failed,  to  sui:)ersede  the  commission  and  have  his  prop- 
erty restored  to  him.  In  1875  the  lunatic  died,  and  plaintiff  brought  this  action  for 
his  servdees  against  the  administrators  of  said  lunatic.  Judgment  for  plaintiff  was 
affirmed,  the  court  holding  that  while  a  hinatic  in  the  cTistody  of  a  committee  is  in- 
capable of  making  a  contract,  and  no  claim  thereunder  could  l3e  enforced  against  his 
estate,  at  his  death  tlie  claim  must  be  adjusted  and  settled  in  like  manner  as  other 
claims  against  the  estate. 


lySJNITY  IN  ITS  2Jh'l)IC0-LEGAL  BEAllIMJS.  143 


TORTS. 

The  i'e8p<)iisi))ility  of  a  hnuitic  for  iiialicious  acts  (lepciids  upon  tlie 
extent  of  his  dh'ect  partici2)ati()n  and  capacity,  and  his  HaV)ility  is  tiius 
limited.  "A  hmatic  is  hable  for  his  torts  so  far  as  to  subject  his  estate 
to  a  suit  for  damages  reverted  to  others  by  his  negligent  management. 
On  principle,  however,  he  cannot  l)e  lield  liable  for  malicious  acts  in 
cases  where  he  is  not  caput  doU."     (Wharton  and  Stille.) 

Tiie  French  courts  in  the  case  of  MuniOiis  vs.  Bnuird  {Jouriud  da 
r<il<(is,  1882,  vol.  xciii.,  p.  ()78),  held  that  the  torts  of  lunatics  when  the 
insanity  has  l)eon  the  result  of  debauch  or  the  ndsuse  of  alcoholic  liquors 
renders  the  individual  civilly  responsible. 

It  has  been  held  that  the  guardian  of  a  deceased  lunatic  must  recover 
for  torts  of  the  deceased  from  the  administrator.  This  was  held  in  the 
case  of  Broivn  vs.  Howe,  9  Gray  (Mass.),  84.*  An  action  for  trespass  may 
be  brought  against  the  administrator  of  a  deceased  lunatic  when  his  tort 
has  resulted  in  the  injury  of  others.t  The  liability  of  a  lunatic  for  the 
carelessness  and  neglect  of  his  guardian  has  been  fixed  in  the  case  of 
Morain  vs.  BevUu,  132  Mass.  87  (1882).| 

LIBELS  AND   SLAJSIDERS. 

These  offenses,  when  committed  by  the  insane,  rarely  form  the  basis 
of  suits  for  damages,  so  clear  is  the  disorderly  mental  condition  of  the 
offending  part3^  Delusions  of  persecution  and  susi^icion  are  so  connnou 
as  to  tiucture  the  speech  and  be  manifested  in  the  conduct  of  their 
possessor.  Even  when  the  '^  partial  insanity  "  of  the  law  exists  aud  the 
defendant's  mind  is  normal  in  most  matters,  such  a  defense  has  often 

*  Calvin  G.  Howe  was  appointed  gnardian  of  Daniel  Saunders,  an  insane  person. 
In  the  settlement  his  account  contained  this  item :  "  For  loss  sustained  by  accountant 
by  fire  caused  by  want  of  care  on  part  of  said  Daniel  Saunders,  over  aud  above  amount 
received  by  insurance,"  which  was  allowed.  Saunders  having  died,  his  administrator, 
Brown,  apiiealed  to  the  Massachusetts  Supreme  Court,  who  reversed  the  decree,  hold- 
ing that  a  claim  of  this  character,  not  arising  from  the  trust,  could  not  be  made  a  part 
of  the  guardian's  account.  The  trust  being  terminated  by  the  death  of  Saimders,  the 
guai'dian's  only  course  was  to  sue  the  administrator  for  the  damage  sustained. 

t  McJnfi/re  vs.  Slinlfi/,  121  111.  6G0.  In  February,  1886,  a  man  was  discovered  con- 
cealed in  a  barn  on  Levi  Sholty's  farm  in  McLean  County,  111.  After  some  efforts  to 
induce  tlie  officers  of  the  law  to  eject  tlie  man,  Sholty,  with  several  neighbors,  gath- 
ered at  the  barn  to  drive  out  the  person,  who  proved  to  be  David  Sholty,  a  brotlier  of 
Levi  Sholty,  and  who  shot  at  tliem.  Shortly  after,  the  barn  was  discovered  to  be  on  fire, 
and  David  appeared  at  the  door  with  a  shot-gun  and  shot  and  killed  Hannah,  the  wife 
of  Levi  Sholty,  whom  he  had  ordered  to  halt  as  she  was  passing  by.  Le\n,  as  admin- 
istrator of  his  wife,  brought  action  of  trespass  against  Mclntyre  as  administrator  of 
David  Sholty,  who  perished  in  the  burning  barn,  and  recovered  judgment.  On  appeal 
the  judgment  was  affirmed. 

The  appeal  was  taken  on  tlie  refusal  of  the  Trial  Court  to  receive  evidence  of  the 
insanity  of  David  Sholty,  wliich  was  the  ground  of  defense.  Held,  vo  error.  The  Su- 
preme Court  said  that  wliile  a  lunatic  is  not  punisliaT)le  criminally  he  is  liable  civilly 
for  a  tort;  if  otlierwise,  those  interested  in  his  estate  miglit  not  take  care  to  prevent 
him  from  injuring  others  ;  and  "  if  parties  can  escape  the  consequences  of  their  injuri- 
ous acts  upon  the  plea  of  lunacy,  tliere  will  be  a  stroTig  temjitation  to  simulate  insan- 
ity, witli  a  view  of  masking  the  malice  and  revenge  of  an  evil  lieart." 

i  Tliis  was  an  action  for  personal  injuries  caused  by  a  defect  in  a  door-step  of  a 
building  owned  by  defeiidant,  wlio  was  at  the  time  of  the  accident  confined  in  an  asy- 


144  ^   SYSTEAL  OF  LEGAL  MEBICIXE. 

been  potent.  {Horner  vs.  Marshall,  5  Mnnf.  16G;  Abrams  vs.  Smith,  8 
Blaekf.  95.) 

The  retrospective  finding  of  a  commission  will  usnally  be  a  good  de- 
fense or  will  mitigate  the  damages  after  the  actnal  snit  has  begam.  *'  If 
the  inquisition  does  not  overreach  the  time  of  libel,  then  the  subsequent 
insanity  of  the  party  can  have  no  bearing  upon  the  question  of  the 
measure  of  damages,  for  a  lunatic  is  ci^dlly  resj)onsible  for  his  torts 
wherever  they  may  have  been  committed."     (Ordronaux.) 

A  case  where  the  issue  was  the  degree  of  insanity,  and  where  it  was 
held  that  though  the  defendant  was  so  insane  as  to  need  a  guardian,  the 
weight  of  his  slander  and  its  consequences  depended  upon  the  hght  de- 
gree of  his  mental  unsoundness,  was  that  of  DicMnson  vs.  Barber,  9 
Mass.  225.* 


DISSOLUTIOX   OF   PAHTNERSHIP   BY  EEASON   OF   INSANITY. 

In  the  matter  of  business  associations,  especially  where  the  interest  of 
one  member  is  moneyed  and  that  of  the  other  is  the  experience  and 
"brains"  he  brings,  lawsuits  may  arise  and  attempts  at  dissolution, 
growing  out  of  the  insanity  of  one  member  of  the  fii'm  and  the  conse- 
quent danger  that  mutual  interests  may  be  wrecked.  The  sane  party 
may  demand  an  inquisition  upon  proof  of  the  insanity  of  the  other,  so 
that  the  copartnership  may  be  dissolved. 


DIPEACmiENT   BY   EEASON   OF   INSANITY. 

In  the  matter  of  guardianship,  where  the  trust  funds  are  being  squan- 
dered, or  where  the  protection  of  the  ward  so  demands,  steps  may  be  taken 
for  the  deposition  of  the  giiardian.  The  most  painful  cases  are  those 
where  the  medical  man  is  required  to  testify  as  to  the  incapacity  from 
old  age  or  mental  disease  of  an  officer  holding  a  position  of  pubhc  trust. 
It  cannot  be  denied  that  even  learned  judges  whose  long  and  honorable 
ser\'ice  has  resulted  in  mental  decay  are  able  in  a  routine  way  to  go 
through  with  familiar  duties  of  the  past,  and  in  fact  those  mental  opera- 
tions which  become  automatic  are  apt  to  fail  long  after  minor  perver- 
sions have  attracted  the  attention  of  his  immediate  friends  and  family. 

lum,  and  had  been  for  several  years — since  1876,  "when  a  guardian  liad  been  appointed 
for  her.  Verdict  for  plaintitf  affirmed  on  aj^peal,  the  Supreme  Court  holding  that  an 
owner  of  real  estate  is  liable  for  defects,  even  vrhen  caused  by  neglect  of  persons  act- 
ing in  his  behalf,  adding,  "and  there  is  no  precedent  and  no  reason  for  holding  that  a 
lunatic,  having  the  benefits,  is  exempt  from  the  responsibilities,  of  ownership  of  real 
estate." 

*  Action  for  slander.  The  complaint  charged  the  defendant  with  having  said  that 
plaintiff  had  been  criminally  intimate  with  his  (defendant's)  wife.  Ujion  the  trial 
the  defendant,  by  his  guardian,  submitted  evidence,  as  a  defense,  that  before  and  at 
the  times  the  words  were  spoken  he  was  insane,  and  still  was  delirious  and  insane. 
He  also  offered  the  depositions  of  two  physicians  to  prove  that  he  was  still  insane, 
which  depositions  the  court  excluded.  The  jury  rendered  a  verdict  for  the  plaintiff, 
which  was  affinned  by  the  Supreme  Court,  who  held  that  where  the  insanity  was 
notorious,  so  that  the  words  could  produce  no  effect,  no  damage  could  be  incurred; 
but  M-here  the  insanity  was  slight,  the  slander  might  have  its  effect — these  were 
questions  of  fact  for  the  jury  to  determine ;  also  that  the  rejection  of  the  opinions  of 
the  physicians  was  proper,  as  they  did  not  appear  to  be  based  on  facts. 


I^'^SAmTY  JX  ITS   MEDICO-LEGAL  BEARINGS.  ]45 

In  such  eases  the  office  of  the  medieal  man  is  a  disafi'i-eeahle  one,  and  he 
should  act  with  more  than  ordinaiy  care  and  prudence.  No  bh)W  is  so 
great  as  that  inflicted  upon  a  sensitive  and  hig-h-minded  person  when  he 
is  made  certain  of  his  intellectual  failure.  The  symptoms  of  ordinary 
disease  or  temporary  manifestations  of  overwork  shoiild  never  form  the 
basis  for  a  hastil}'  expressed  opinion. 


INSANITY  AND   LIFE-INSURANCE. 

The  question  of  insanity  in  relation  to  life-insurance  occasionally 
arises,  and  is  made  the  basis  of  refusal  to  2:)ay  the  amount  of  the  poHcy 
upon  the  part  of  the  companies.     (See  Dr.  Symond's  article,  vol.  i.) 

It  sometimes  happens  that  an  individual  insures  his  life  and  fails  to 
state  that  he  has  suffered  from  a  nervous  disease  which  is  the  precursor 
of  a  form  of  insanity.  A  case  repoi'ted  by  Taylor  and  Tardieu  *  is  that 
of  a  gentleman  who  insured  his  life,  afterward  becoming  insane.  The 
company  refused  payment,  asserting  that  the  insured  was  aware  of  his 
malad}^  when  he  applied  for  a  polic}^,  and  refused  to  so  state.  The  jury 
decided  for  the  defendant,  and  the  judge  charged  the  jury  that  they  must 
decide  if  the  mental  disease  had  a  tendency  to  shorten  life,  for  in  this 
case  the  dissimulation  that  had  been  proved  was  important;  if  the  alien- 
ation had  this  tendency  they  nmst  decide  in  favor  of  the  defendant. 

One  of  the  oldest  cases  of  this  kind  is  that  rejiorted  by  Beck,  and  the 
high  position  of  the  insured  party  gives  the  case  much  interest : 

''  In  1824:  a  policy  was  effected  by  the  Baron  von  Lindenau  on  the 
life  of  Frederick  IV.,  Duke  of  Saxe-Gotha  and  Altenburg,  in  the  Atlas 
Insurance  Company.  The  duke  died  on  the  11th  of  February,  1825,  and 
the  insurers  refused  to  pay  the  sum  insured  for. 

"  On  the  trial  it  appeared  that  Lindenau  had  stated  in  his  application 
that  the  duke  was  not  gouty,  asthmatic,  or  consumptive,  or  suliject  to 
fits ;  that  he  had  never  had  apoplexj',  and  that  he  had  no  disease  tending 
to  shorten  life.  Two  physicians  of  the  duke  certified  that  .since  tlie  year 
1809  he  had  had  a  dimness  of  the  sight  from  amaurosis  in  the  left  eye, 
and  since  1819  had  been  'hindered'  in  liis  speech  from  lia\ang  had  an 
inflammation  of  the  chest,  of  which  he  had  been  perfect^  cured.  In  a 
communication  from  an  agent  in  Germany  it  was  mentioned  that  the 
duke  had  formerly  led  a  dissolute  life,  by  which  he  had  lost  the  use  of 
his  speech,  and,  according  to  some,  that,  also,  of  his  mental  faculties, 
which,  however,  is  contradicted  by  the  medical  men.  On  this  the  com- 
pany, instead  of  asking  an  ordinary  premium  of  £2  17s.  percent,  per 
annum,  required  £8  percent.  It  iiow^,  how^e\'er,  appeared  that  the  duke 
had  been  afflicted  Avith  ahnost  a  total  loss  of  speech  from  1822  to  the 
time  of  his  death,  which  one  of  the  physicians  attributed  to  local  paraly- 
sis; and  that  he  had  periodical  catarrhal  affections  accompanied  with 
fever.  The  chamberlain  of  the  duke,  in  his  examination,  mentioned 
that  he  had  never  complained  of  pain  in  his  head.  He  ate,  drank,  and 
slept  well,  but  could  not  speak.  Dr.  Doi'l,  physician  to  the  duke,  agreed 
that  his  intellectual  faculties  were  impaired,  although  his  bodily  health 
was  good.     On  examination  after  death,  no  chronic  disease  was  dis- 

*  AnnaUs  (VITi/giciic  riihliqiie,  Lxxvi.,  p.  152. 


146  ^   SYSTEM  OF  LEGAL  2IEDICLXE. 

covered  in  tlie  viscera  or  any  part  of  the  trnnk ;  bnt  in  the  head  was- 
fonud  a  large  tumor  six  inches  in  length,  two  in  breadth,  and  one  in 
depth,  which  not  only  pressed  on  the  iDrain,  bnt  had  depressed  the  skull 
at  its  base.  It  was  inferred  that  this  tumor  had  commenced  in  earty  life. 
The  defense  was  that  there  had  been  a  suppression  of  material  facts. 
Dr.  Green,  an  eminent  Enghsh  siu'geon,  gave  it  as  his  opinion  that, 
from  the  history  of  the  case  merely,  there  were  no  symptoms  of  organic 
disease.  He  further  thought  that  the  tumor  in  the  skull  must,  during 
life,  have  been  in  a  passive  state,  and,  from  its  appearance  on  dissection, 
that  it  must  have  been  formed  in  early  life.  He  was  only  willing  to 
allow  that  the  sj^Tnptoms  mentioned  above  would  lead  to  a  suspicion  of 
disease  in  the  head;  and  he  was  disposed  to  ascribe  the  difficulty  of 
speech  to  want  of  volition,  and  not  to  tumor  in  the  brain.  In  replj^, 
however,  to  a  question  of  Lord  Tenterden,  he  answered:  'If  I,  as  a 
medical  man,  were  asked  by  an  insiu-ance  company  concerning  the  state 
of  a  man's  health  who  was  unwilling  to  move,  who  was  subject  to  control 
upon  his  intellect,  and  who  had  lost  his  speech,  I  should  not  consider 
myself  at  liberty  to  forbear  mentioning  these  circumstances.'  Lord  Ten- 
terden, who  tried  the  cause,  said  this  was  sufficient,  and  that  he  should 
charge  the  jury  that  if  any  material  facts  relative  to  the  duke's  health 
were  concealed,  then  the  policj^  was  void.  The  plaintiff  elected  to  be 
nonsuited,  and  subsequently  made  an  effort  to  obtain  a  new  trial,  bnt  it 
was  refused." 

A  French  decision  holds  that  if  a  person  applies  for  a  pohcy  and  with- 
holds the  fact  that  he  has  been  insane,  or  has  a  disease  which  may  lead 
to  insanity,  his  policy  is  null  and  void,  and  he  cannot  expect  the  retui-n 
of  the  premium,  even  though  the  person  insui-ed  may  die  of  some  other 
disease. 

Paretic  dementia  may  sometimes  enter  into  the  question  of  life-insur- 
ance. A  case  is  related  by  Legrand  du  Saulle  which  shows  how  one  of 
the  French  companies  was  victimized.  Two  brothers  went  to  the  office 
of  a  Parisian  alienist,  and  the  elder  had  a  private  consultation,  the  residt 
being  that  he  was  informed  that  the  other  had  the  incipient  signs  of 
paretic  dementia,  and  that  death  would  occur  in  three  or  four  years. 
They  departed,  and  the  result  was  that  a  policy  of  insurance  was  pro- 
cured for  100,000  francs.  Three  years  afterward  the  elder  brother 
quietly  pocketed  the  results  of  the  robbery. 

Another  case  is  reported  by  Legrand  du  Saulle.  A  physician  well 
known  in  science  had  for  nine  years  before  his  death  a  life-policy  for 
100,000  francs.  He  suddenly  presented  the  signs  of  great  cerebral 
excitement,  became  boasting,  and  wrote  and  spoke  in  an  exaggerated 
manner.  He  again  went  to  the  companies  and  insured  for  500,000 
more.  "Ulien  the  contract  was  prepared  and  ready  for  signature,  the 
manner  of  the  doctor  was  so  vehement  and  excited  that  the  agent  be- 
lieved him  to  be  drunk,  and.  under  the  pretext  of  having  forgotten  to 
insert  an  indispensable  clause  rook  back  the  policy.  Upon  the  following 
day  the  medical  man  was  sent  to  an  asylum,  and  six  months  afterward 
died  of  paretic  dementia.  The  company  paid  to  the  widow  the  100,000 
francs,  and  considered  itself  very  fortunate  in  not  having  to  add  the 
half-milhon  francs  the  husband  desired  to  insm*e  for. 

Henry  C.  Koss  had  effected  an  insiirance  on  his  life  with  defendant, 
and  subsequently  committed  suicide  by  taking  a  dose  of  laudanum  while- 


JXS.IMTV    I.\    n\S    MEDK'O-LKCAL    JSh'.iJUXdS.  147 

insane.  In  his  applicalion  for  a  policy  he  had  stated  tliat  no  member  of 
his  family  had  l)een  afflicted  witli  insanity  or  other  hereditary  disease, 
Imt  admitted  that  liis  father  had  died  of  a  brain  disease  caused  Ijy  a  hurt. 
On  the  trial  it  whs  proved  that  his  father  liad  received  an  injury  on  his 
head  in  cliildiiood,  resultiiif"'  in  a  weakeninji'  of  his  mental  powers,  and 
that  at  the  aii'c  of  forty-seven  he  was  placed  in  an  insane  asylum,  and 
aftei-ward  died.  On  this  testimony  phiintiff  was  nonsuited,  but  on  appeal 
the  Court  of  Appeals  reversed  the  judgment  of  nonsuit  and  ordered  ab- 
solute judii'ment  for  plaiutitf,  {Newton  vs.  Mutual  Benefit  Life  Insurance 
6V,  7GN.  Y.  426.) 

THE   LIABILITY   OF   CUSTODIANS. 

The  responsibility  of  the  physician  who  shall  receive  into  his  asylum 
an  insane  patient  extends  only  so  far  as  the  proper  care  of  such  a  patient 
is  concerned.  Under  the  laws  of  New  York,  and  so  far  as  this  particular 
matter  is  concerned,  the  procedui'e  is  almost  universal — the  patient  must 
Tje  committed  upon  order  of  the  court,  upon  proper  medical  affidavits. 

Under  these  circumstances  the  asylum  physician  is  a  mere  custodian 
and  can  only  discharge  the  patient  upon  recovery  or  uj)on  the  assump- 
tion of  responsibility"  by  the  next  of  kin,  provided,  in  his  judgment,  he 
thinks  it  safe  to  make  others  the  caretakers  of  the  patient.  Under  all 
other  circumstances  the  application  of  a  wi-it  of  habeas  corpus  by  the 
patient  or  his  friends  is  in  order.  If  he  is  found  to  be  improperly  held 
lie  is  discharged.  Until  this  time  the  asylum  superintendent  is  prop- 
erly the  representative  of  the  court,  who  assumes  the  responsibility. 

The  patient's  rights  to  damages,  if  there  be  any,  are  to  be  determined 
by  a  suit  against  those  upon  whose  recommendations  he  was  committed 
by  the  court.  Their  defense  must  be  that  which  is  applicable  in  other 
professional  matters,  and  must  consist  in  CAidence  showing  that  they 
acted  in  good  faith  and  with  an  intelligent  knowledge  of  the  requirements 
of  the  profession.* 

Maltreatment,  of  course,  if  proved,  entitles  the  patient  to  damages. 

*  Ayers  vs.  BiisscU,  50  Hun,  282.  On  April  1.5,  1887,  plaintiff  ■was  committed  to  an 
insane  asylum  in  Albany,  where  he  was  kept  until  the  27th  of  April,  on  certificates  of 
Drs.  Selwyn  A.  Russell  and  Daniel  V.  O'Leary  that  he  was  insane.  On  April  18th  the 
plaintiff  appealed  from  the  commitment,  and  a  jury  was  called  who  on  tlie  27th  of 
April  declared  him  to  be  sane,  and  he  was  released.  The  j^laintitt'  then  brought  this 
action  against  Drs.  Riissell  and  O'Leary,  and  Anthony  Gould  as  Recorder  of  Albany, 
for  false  imprisonment.     The  defendants  demurred,  and  the  demurrer  was  sustained. 

On  appeal  to  the  General  Term  the  judgment  was  affirmed  as  to  Gould,  and  re- 
versed as  to  Russell  ami  O'Leary,  and  the  demurrer  as  to  them  overruled  on  the  ground 
that  as  the  complaint  charged  them  with  lack  of  ordinary  care  and  prudence,  their 
demurrer  (which  was  on  the  ground»tliat  facts  did  not  constitute  cause  of  action)  ad- 
mitted the  allegations  of  the  complaint.  The  court  lield  tliat  tlieir  certificate  was  not 
a  privileged  communication  unless  they  had  discliarged  their  duty  properly. 

Hurlcliy  vs.  ]\[arflnc  rt  al,  ,31  N.  Y.  State  Rejiorter.  471  (Supreme  Court.  Third 
Dept.,  Mfcv  26,  1890).  In  October,  1889,  an  inquisition  was  held  as  to  phnntift""s  lu- 
nacy, at  which  defendants,  as  pliysicians,  made  alleged  false  statements  as  to  plaint- 
itY's  pulse,  temperature,  condition  of  mind,  etc.,  and  commitment  was  made  to  the 
Hudson  River  State  Hospital,  wliere  she  was  confined  for  two  years  ami  five  montlis. 
The  plaintift'  brought  this  action  after  her  release  in  1888,  for  $20,000  damages, 
and  on  tlie  trial  a  motion  for  nonsuit  was  granted  on  the  ground  tliat  tliis  was  an 
action  for  false  imprisonment,  which,  under  section  384  of  the  Code  of  Civil  Procedure, 
Avas  limited  to  two  years.     On  appeal  to  the  General  Term  this  decision  was  affirmed. 


148  ^   SYSTEM  OF  LEGAL  MEDICLNE. 


IMEDICAL   WITNESSES. 


Attention  has  been  elsewhere  directed  to  the  appearance  of  expert 
witnesses  in  conrts  of  law,  and  the  difficulties  and  abuses  Avhich  attend 
the  introduction  of  this  kind  of  testimony  have  been  pointed  out.  Much 
of  the  disrepute  into  which  hired  testhnony  has  fallen  is  undoubtedly 
due  to  a  kiud  of  partisanship  which  many  men  find  it  difficult  to  avoid, 
for  the  engagement  of  their  services  implies  a  bid  for  actual  help  in 
advancing  a  side  by  the  building  up  of  theories  or  reasons  for  the  sup- 
port of  a  more  or  less  tenable  position.  If  the  expert  be  careless  of  Ms- 
reputation,  weak,  or  corrupt,  he  will  lend  himself  to  the  side  of  the  case 
upon  which  he  has  been  retained,  and  in  reality  he  becomes  a  pleader, 
prostituting  his  knowledge,  stretching  a  point,  or  burying  his  conscience. 
If  he  is  not  absolutely  free  his  sympathies  will  be  appealed  to.  It  there- 
fore becomes  him  to  avoid  espousing  the  cause  of  any  "  side  "  too  ardently, 
or  being  actuated  by  a  desu-e  to  "get  back"  at  the  cross-examiner.  In 
other  words,  the  medical  witness  who  is  called  to  give  his  opinion  regard- 
ing the  facts  submitted  to  him  should  emulate  the  judge  upon  the  bench 
in  his  impartiality.  One  of  the  unavoidable  evils  of  the  present  system 
is  the  liijpotlietkal  question,  which  is  supposed  to  embody  the  facts  of  the 
case,  but  in  reality  is  often  distorted,  disingenuous,  and  is  roughly 
handled  and  more  or  less  emasculated  before  the  witness  is  finally 
allowed  to  pass  judgment  upon  it.  When  the  answer  is  given  the  medi- 
cal gentleman  in  the  witness-chair  is  obliged  to  consider  section  by 
section,  and  an  attempt  is  made  to  elicit  a  categorical  answer,  which  is. 
often  impossible.  What  may  constitute  insanity  as  a  whole  may  when 
dissected  mean  nothing.  By  this  means  it  is  possible  to  get  a  truthful 
negative  answer  to  many  of  the  elements  of  real  insanity.  "Do  you 
consider  the  fact  that  a  nuin  is  slovenly  in  his  habits  an  infalhble  sign 
of  insanity?"  may  be  asked,  and  the  witness  of  course  answers,  "No"— 
while  this  very  untidiness,  taken  with  other  indications,  may  be  a  verj 
important  element  of  the  mental  disease.  The  medical  man  should 
therefore  be.on  his  guard  and  refuse  in  such  a  case  to  give  anything  but 
a  qualified  answer.  The  witness  can  always  avail  himself  of  the  privilege 
of  qualifying  his  answers,  for  he  cannot  be  made  to  demean  himself  by 
giving  a  nonsensical  definition  which  will  stultify  him  as  a  scientific  man.. 
It  is  wiser  and  better  for  a  physician  to  demand  a  personal  examination, 
but  in  posthumous  cases,  of  course,  the  hypothetical  question  is  all  that 
is  available.  Whether  in  civil  or  criminal  cases,  we  are  to  determine 
the  influeuces  that  may  destroy  the  responsibility  of  an  individual,  and 
it  should  alM'^ays  be  borne  in  mind  that  the  offices  of  the  physician  are 
only'those  in  which  he  is  warranted  in  forming  an  opinion  relative  to 
the  enfeeblement  of  mind  through  disease.  Questions  of  law  do  not 
concern  him,  and  the  courts  will  not  permit  him  to  express  more  than 
what  he  knows  regarding  the  medical  aspects  of  the  case.  Neither  will  he 
be  permitted  to  testify  to  the  legal  meaning  of  the  facts  submitted  to  him, 
or  their  pertinency  to  the  case.  He  should  always  remember  the  dignity 
of  his  calling  and  never  lose  his  temper,  no  matter  how  much  galled  he 
may  be  by  the  impertinence  of  the  opposing  counsel,  who  is  not  always  a 
gentleman.  He  sliould,  however,  never  be  flurried,  never  give  hui-ried 
answers,  and  should  demand  time  for  his  full  answer  if  "choked  off"  or 


IXSANITY  JX  ITS   MEDICO-LEGAL   BEARIXGS.  149 

interrupted.  He  sliould  never  sliow  an  eagerness  to  testify,  or  an  argu- 
mentative spirit.  Plis  testimony  should  be  given  in  a  cool,  impartial 
manner.  Pie  should  he  on  the  alert  and  avoid  the  possibility  of  being 
trapped  by  his  ingenious  legal  opponent.  He  should  avoid  being  drawn 
into  discussions  upon  various  other  subjects  which  are  foreign  to  the 
ease  in  hand,  and  if  these  be  not  strictly  medieval,  the  witness  may  refuse 
to  answer — at  least  so  far  as  he  may  be  made  to  pose  as  an  expert  iu 
some  other  held.  This  applies  especially  to  abstract  theology,  which 
may  be  a  stumbling-block  which  it  is  well  to  avoid. 

An  expert  is  received  as  such  on  his  declaration  and  upon  presentation 
of  qualifications  or  evidences  of  his  experience.  A  physician  may  avoid 
the  obligation  of  giving  special  opinion  by  the  avowal  of  non-cxpertism 
in  the  subject  which  forms  the  basis  of  the  questions  i)ropounded  to  him. 
For  example,  a  surgeon  can  properly  disclaim  being  an  expert  in  mental 
diseases,  or  a  general  physician  can  properly  refuse  to  pose  as  a  special 
authority  of  any  kind. 

"•  An  expert  cannot  be  examined  as  to  a  matter  of  common  know^ledge 
concerning  which  a  juror  may  form  an  independent  opinion,  nor  as  to  a 
matter  of  mere  mental  or  moral  philosophy,  or  of  domestic  jurispru- 
dence." (Whai'ton  and  Stille,  section  262,  p.  236.)*  The  relevancy  of  the 
matter  which  is  to  become  the  basis  of  an  expert  opinion  is,  of  course,  to 
be  determined  by  the  court.  The  offices  of  the  medical  A^itness  are  limited 
to  the  elucidation  of  such  facts,  so  far  as  they  constitute  insanity,  that 
will  incapacitate,  and  he  should  be  ready  to  gauge  their  importance  and 
tell  how  they  affect  responsibility. 

It  is  not  here  necessary  to  enter  into  a  discussion  of  true  and  false 
experts,  and  of  the  value  of  their  testimony.  That  there  is  need  for 
reform  is  undeniable,  and  that  the  couji-ts  do  not  exercise  sufficient  care 
in  fixing  the  status  of  medical  witnesses  is  equally  true.  The  strictures 
of  legal  writers,  courts,  and  others  are  just,  so  far  as  the  existence  of 
demoralization  goes.  As  the  law  is  administered,  many  jjersons  can  be 
found  who  are  ready  to  arrogate  knowledge  and  position  they  do  not 
deserve.  The  dignified  ahenist  of  experience  and  reputation  is  con- 
fronted by  the  impostor,  whose  glib  manner  and  bizarre  '^  popular  sci- 
ence" sometimes  impresses  the  susceptible  juryman  as  does  the  proprie- 
tary-medicine advertisement,  and  whose  experience  of  medicine  and  its 
exponents  is  confined  to  the  quack  or  ciu'e-all.  The  law  is  largely  respon- 
sible for  all  this. 

The  use  of  ).>ooks  in  com't  is  not  allowed  where  such  authoiities  are 
introduced  as  e^ddence ;  but  they  uuiy  be  read  to  a  witness  for  the  j^iu-- 
l)0se  of  ascertaining  how  far  they  agree  with  the  opinion  expressed  by 
him.  He  may  be  examined  as  to  the  standing  of  other  experts  or 
authorities,  but  should  be  careful  in  expressing  his  opinion  of  a  personal 
nature.  Under  the  hiAvs  of  the  State  of  New  York  and  some  other  States, 
a  physician  is  not  permitted  to  disclose  information  derived  in  the  man- 
agement of  a  patient,  unless  the  latter  authorizes  and  requests  him  sa 
to  do. 

The  compensdtioii  of  ^'' expert^''  wifuessc^  and  allowance  are  usual  when 
they  give  expressions  of  opinion,  or  when  time  and  labor  have  been 
expended  in  the  preparation  of  the  case.     There  is  no  impropriety  iu 

*  Whartou  on  Evidence,  section  434. 


150  ^   SYSTEM  OF  LEGAL  MEDLCLXE. 

declaring  tlie  fact  that  coinpensatiou  is  expected ;  and  tliongli  bound  to 
give  medical  testimony  wMch  deals  witli  matters  of  fact  for  no  other 
compensation  except  the  fees  of  ordinary  witnesses,  it  does  not  appear 
that  any  opinions  implying  the  exercise  of  special  knowledge  which  has 
"been  gained  at  the  cost  of  time  and  money  should  be  given  gratiiitonsly. 
(See  vol.  i.  p.  614.)  It  has  been  held  that  the  findings  of  a  post-mortem 
examination  do  not  constitnte  expert  testimony,  and  thongli  the  witness 
is  entitled  to  pay  for  making  such  an  examination,  he  shoidd  be  compelled 
to  testify.* 

The  case  of  Bills  vs.  The  State  of  Indiana,  59  Ind,  15,  is  one  which 
altered  the  statutes  of  that  State  so  that  at  present  the  gi^■ing  of  exjDert 
testimony  is  compulsory.  This  is  the  case  of  Dr.  Thomas  J.  Dills,  who 
was  committed  for  contempt  in  the  Hamilton  Case,  mth  Dr.  Buchanan. 
He  ref nsed  to  answer  the  questions  referred  to  in  the  Buchanan  Case, 
saying :  "  I  did  not  offer  my  services  here  any  more  than  I  do  my  pro- 
fessional services  elsewhere.  I  was  sent  for  and  have  come.  My  time 
and  my  skill  are  my  capital,  and  I  cannot  sm-render  them  gTatuitously 
to  any  but  the  poor,  since  it  is  by  my  professional  opinion  that  I  earn 
my  living.  There  is  a  distinction  between  a  man  who  sees  a  fact,  and  is 
called  to  prove  it  in  a  coui-t  of  justice,  and  a  man  who  is  selected  to  give 
his  opinion  on  a  matter  with  which  he  is  peculiarly  conversant,  from  the 
natui-e  of  his  emplojnnent  in  life.  The  former  is  bound,  as  a  matter  of 
public  duty,  to  speak  to  a  fact  which  happens  to  have  fallen  within  his 
knowledge  ;  without  such  testimony  the  course  of  justice  would  be  stopped. 
The  latter  is  under  no  such  obhgation.  For  the  above-named  reasons  I 
respectfully  decline  to  give  the  opinion  of  an  expert  in  the  case  now 
pending,  except  upon  the  pajanent  of  my  fee  in  advance."  In  this  case 
Biddle,  C.  J.,  wrote  an  elaborate  oj)inion  for  affirmance,  which  was,  how- 
ever, dissented  from  by  a  majority  of  the  judges,  and  the  judgment  was 
therefore  reversed. 

EXAJ\nNATIOX   OF   THE   PATIENT. 

The  duty  of  the  physician  is  one  implpng  a  most  serious  responsi- 
bility, for  upon  his  say  largely  depend  the  freedom  and  peace  of  mind,  the 
iDusiuess  interests,  of  a  feUow-man,  and  the  happiness,  perhaps,  of  a  fam- 
ily. His  neglected  obligation  to  society  may  also  be  questioned,  should 
he  make  a  mistake  and  permit  a  dangerous  lunatic  to  go  at  large.  Finally, 
his  own  professional  position  may  be  compromised  by  a  blunder,  and  he 
may  lay  himself  open  to  censure  of  all  kinds,  as  well  as  a  possible  lawsuit. 
It  therefore  becomes  him  to  use  the  utmost  care  and  careful  exercise  of 

*  Summers  vs.  The  State,  5  Tex.  App.  365.  On  the  trial  of  Summers  for  murder.  Dr. 
Arthur  E.  Spohn  was  called  as  a  witness  for  the  State,  and  testified  to  linding  the 
deceased  injured  and  having  attended  him  until  he  died.  He  also  stated  the  nature 
of  his  injuries.  After  death  he  made  a  post-mortem  examination,  but  refused  to  state 
the  cause  of  death,  claiming  that  his  knowledge  was  obtained  by  professional  skill ; 
and  the  eom*t  sustained  him.  Summers  was  convicted,  and  on  appeal  the  refusal  of 
Dr.  Spohn  to  testify  was  noticed,  the  court  saying :  "  The  coiu-t  may  compel  a  phy- 
siician  to  testify  as  to  the  result  of  a  post-mortem  examination.  .  .  .  Dr.  Spohn  has 
doubtless  been  misled,  in  taking  the  position  he  did,  by  the  misconceptions  of  cer- 
tain writers  on  medical  jurisprudence.  ...  A  medical  expert  could  not  be  compelled 
to  make  a  post-mortem  examination  unless  paid  for  it ;  but  an  examination  having 
already  been  made  by  him,  he  could  be  compelled  to  disclose  the  result  of  that  exam- 
ination." 


IXSAXITY  IX  ITS   MKDICO-LECAL    liEAIlIXOS.  151 

judgnieiit  ill  furniiii<;'  uu  opinion.  He  should  put  into  oi)eration  a  system 
of  iuvestigiition  ))y  wliieh  he  can  learn  the  patient's  antecedent  history, 
habits,  feeliiiiifs,  associations,  and  (conduct  generally,  and  should  deter- 
mine the  time  and  manner  of  departure  from  ordinary  mental  health, 
and  the  evidence  of  weakness.  As  many  sources  of  information  as  possi- 
ble should  l)e  made  use  of,  and  the  statements  of  interested  i)ersons  be 
given  their  proper  W(?ight.  Business  papers  and  letters  and  other  pro- 
ductions of  the  alleged  Irmaticr  written,  when  not  under  oljservation  or  at 
a  time  when  he  did  not  siis])ect  he  was  watched,  should  l)e  inspected,  and 
will  often  give  a  clew  to  tlie  nature  of  the  disease.  So  far  as  the  a<^tual 
■examination  itself  is  concerned,  I  would  advise  as  constantly  as  possible 
the  maintenance  of  an  attitude  of  perfect  frankness.  It  is  only  the  due 
of  the  alleged  lunatic,  and,  unless  his  conduct  is  palpably  disorderly  and 
his  attention  unfixed,  he  should  l)e  engaged  in  conversation  as  a  sound 
person.  Siuili  a  conversation,  if  sufficiently  extended,  will  nearly  always 
result  in  the  discf)very  of  his  delusion  or  other  evidence  of  aberration. 

The  ftrst  part  of  this  article  contains  information  that  will  serve  as  a 
hint  to  the  examiner,  l)ut  every  case  has  its  own  peculiarities,  and  the  use 
of  tact  and  patience  will,  with  a  knowledge  of  the  featiu^es  of  mental  dis- 
ease, help  the  physician  more  than  anything  else.  Tardieu  suggests  the 
following  ])oints : 

"(a)  Mfittal  ^taie. — Three  orders  of  facts  should  be  investigated:  1. 
The  intellectual  troubles.  2.  The  perversion  of  the  affective  faculties 
and  the  instincts.     3.  Alteration  of  the  sensorial  fimctions. 

"The  intellectual  disorders  consist  in  a  general  derangement,  marked 
by  delirious  conceptions,  with  or  without  complete  abolition  of  judgment, 
memory,  and  conscience ;  afterward  commonly  in  a  partial  derangement 
of  understanding.  From  a  medico-legal  point  of  ^dew  the  most  direct 
and  immediate  result  of  the  disorder  of  the  intellectual  faculties  is  a 
perversion  of  will  and  a  resulting  impairment  in  action,  either  in  an 
absence  of  control  or  purpose,  or  in  action  which  bears  the  impress  of 
incoherent  or  erroneous  ideas. 

"  Disorders  of  the  affective  faculties  are  constant  in  insanity.  There 
is  more  or  less  alteration  of  affections  and  instincts.  The  more  natural 
sentiments  are  abolished  or  perverted,  and  the  instinct  is  sometimes 
abolished  as  w^ell. 

"  The  sensorial  troubles  are  singular  and  characteristic  in  insanity, 
and  hallucinations  and  illusions  are  the  most  important.  .  .  . 

"(6)  Soniatir  State. — The  position,  attitude,  walk,  gestures,  the  dress, 
malformationof  head,  physiognomy,  expressi(m.  .  .  .  The  circulation  and 
temperature  are  diminished  in  the  inaction  of  melancludia  and  increased 
in  the  agitation  of  mania.  The  general  sensibility  is  exalted  or  perverted 
in  monomania,  or  diminished  to  the  point  of  analgesia  in  lypemania. 
The  spasms,  the  startings,  the  muscular  twitchings,  the  partial  paralyses 
of  sensation  and  motion,  indicate  a  gi-ave  alteration  of  the  nervous  cen- 
ters. The  embarrassment  of  speech,  the  unequal  dilatation  of  the  pupils, 
the  permanent  deviation  of  the  uvula,  the  ataxia  of  movement,  suggest 
genei-al  paresis.  Finally  we  are  to  recognize  all  the  symptoms  which  are 
connected  more  or  less  directly  with  nu-ntal  alienation :  vertigo,  muscas 
volitantes,  cutaneous  and  neuropathic  manifestatiims,  the  mobility  of  the 
tongne,  and  scars  which  may  ])e  indicative  of  epilepsy,  or  traces  of  cica* 
trices  which  may  be  the  result  of  attempted  suicide." 


152  -4   SYSTEM  OF  LEGAL  MEDICINE. 


"habitual  drunkards." 


It  is  an  important  matter  to  determine  what  constitutes  "  liabitiial 
drunkenness,"  and  courts  of  law  take  widely  differing  views.  In  the  case 
of  Blcincy  vs.  Blancij,  12G  Mass.  Reports,  205,  a  decision  was  rendered  in 
an  action  for  divorce  on  the  ground  of  habitual  drunkenness.  It  wa& 
proved  that  defendant  for  twelve  or  fifteen  years  past  became  grossly 
intoxicated  at  least  three  times  a  year,  and  remained  in  that  condition 
from  seven  to  ten  days  each  time ;  that  when  these  sj)eUs  came  he  was 
sent  to  an  inebriate  asylum,  where  he  remained  until  thej  passed ;  that 
between  the  spells  he  would  drink  nothing,  but  that  any  excitement 
would  make  him  drink.  Held,  on  appeal  to  the  Supreme  Court,  that  this 
was  sufficient  proof  of  habitual  drunkenness. 

In  the  case  of  Wheeler  vs.  Wheeler,  53  la.  511,  a  divorce  was  granted 
the  plaintiff,  who  was  the  victim  of  the  husband's  violence  during  his 
drunken  excesses,  although  at  other  times  he  was  sober  and  was  able  to 
conduct  his  business.  The  plaintiff  and  defendant  were  married  in  1859.. 
Previous  to  that  time  defendant  was  addicted  to  liquor,  and  was  fre- 
quently drunk.  After  his  ma,rriage  he  became  an  habitual  drunkard,  and 
his  wife  sued  for  a  divorce  on  that  ground,  and  also  because  of  inhuman 
treatment.  The  divorce  was  granted.  Although  he  was  always  sober 
during  business  hours,  he  was  habitually  drunk  at  other  times,  and  when 
in  that  condition  abused  his  wife,  calling  her  vile  names  and  openly 
charging  her  with  unchastity.  On  appeal  the  Supreme  Coin-t  affirmed 
the  decree  of  divorce.* 

The  English  Habitual  Drunkards'  Act  of  1879  defines  an  "  habitual 
drunkard"  as  a  "person  who,  not  being  amenable  to  any  jurisdiction  in 
lunacy,  is,  notwithstanding,  by  reason  of  habitual  intemperate  drinking- 
of  intoxicating  liquor,  at  times  dangerous  to  himself  or  herself  or  to 
others,  or  is  incapable  of  managing  himself  or  herself,  and  his  or  her 
affairs."  (Kerr.)  In  England  such  an  habitual  drunkard  may  be  com- 
mitted to  a  retreat,  either  upon  his  own  application  or  upon  the  affidavits 
of  two  persons,  for  a  period  not  exceeding  twelve  months.  He  is  in  all 
respects  treated  like  an  insane  person,  so  far  as  his  loss  of  liberty  is  con- 
cerned. In  the  United  States  the  only  way  in  which  it  is  now  possible 
to  have  an  habitual  drunkard  secluded  is  through  the  intervention  of  the 
police — the  occasion  of  some  disorderly  act  being  chosen  for  a  com- 
plaint. If  his  habitual  drunkenness  is  connected  with  symptoms  of  in- 
sanity, he  may  of  com-se  be  committed  to  an  asylum  or  institution  as  any 
other  lunatic,  but  superintendents  of  asylums  are  not  disposed  to  detain 

*  Mary  Williams  (wife)  vs.  J.  W.  Goss  (husband),  43  La.  Ann.  868.  This  was  an 
action  for  separation  on  the  groimd  of  habitual  intemperance.  The  defendant  owned 
a  small  store,  of  .which  liis  wife  had  been  the  head  for  several  years.  It  was  shown 
that  he  "  was  addicted  to  excessive  drink  "  ;  drunk  often  two  or  three  times  a  week ; 
had  frequently  been  undressed  and  helped  to  bed ;  was  frequently  away  from  home 
all  night,  and  often  carried  home  drunk  by  strangers.  He  had  often  taken  seven  or- 
eight  drinks  a  day  in  one  store,  and  sometimes  bought  by  the  bottle — fifteen  cents' 
worth.  He  had  locked  himself  in  a  bedroom  on  one  occasion,  and  with  a  loaded  gun 
lay  in  wait  for  imaginary  assassins.  He  had  been  on  sprees  of  three  or  four  days  at 
a  time,  and  was  known  as  "  a  drinking  man."  There  was  no  evidence  that  he  had  be- 
come v'hollji  incapacitated  for  business.  The  decree  was  granted,  and  the  Supreme- 
Court  affirmed  the  judgment. 


IXSAXITY  IX  ITS  MEDICO-LEGAL   BEAIUXGS.  153 

such  subjects  unless  the  departure  from  mental  health  be  a  prolonged 
and  clear  one.  The  use  of  the  word  ''  di-unkenness  "  does  not  inchide 
the  intoxication  produced  by  other  agents,  as  was  held  in  the  case  of 
Youn(/s  vs.  Yoioujs,  130  111.  230.* 

Tlie  commitment  of  an  inebriate  may  often  lead  to  very  disagreeable 
results — the  medical  men  or  the  friends  being  sometimes  sued  by  the 
person  committed.  The  case  of  Jason  L.  Blodgett,  reported  by  Dr. 
Fisher  {Boston  Medical  and  Surgical  Journal,  June  G,  1881), .is  so  interest- 
ing that  I  may  be  pardoned  for  referring  to  it  rather  extensively,  using 
the  reporters'  language. 

"  A  suit  was  brought  two  years  ago  in  the  Massachusetts  Supreme 
Court  by  Jason  L.  Blodgett  against  his  divorced  wife.  Major  Jones,  now 
on  the  Board  of  Police  Commissioners  of  Boston,  and  Drs.  Fisher  and 
Youngmau  for  a  conspiracy  to  imprison  him  in  the  Taunton  Lunatic 
Hospital  on  the  false  charge  of  insanity  ;  also  for  assault  and  battery  in 
causing  his  arrest ;  and  for  taking  his  property,  ruining  his  business,  and 
causing  great  damage  to  his  reputation  and  feelings ;  for  all  of  which 
damages  to  the  extent  of  $15,000  were  claimed.  His  legal  adviser  at 
first  was  "WilUani  H.  Towne,  who  afterward  called  to  his  assistance  Ed- 
ward Avery.  The  defendants  were  represented  by  Edward  P.  Brown. 
At  the  first  trial  the  plaintiff's  petition  was  dismissed  for  informahty 
and  illegal  contents.  Major  Jones  was  excused,  as  having  had  nothing 
to  do  with  the  particular  commitment  complained  of,  the  plaintiff  having 
been  sent  to  Taunton  twice ;  and  Mrs.  Blodgett,  having  been  his  wife  at 
the  time  of  the  alleged  offense,  could  not  be  proceeded  against.  This 
left  the  two  physicians  standing  alone ;  and  after  six  months  the  case 
was  called  again,  unexpectedly,  at  the  close  of  the  summer  vacation,  when 
police  officers,  who  were  ini23ortant  witnesses,  were  absent.  The  "v^afe, 
whose  testmiony  was  almost  absolutely  essential  to  the  defense,  had  liid- 
den  herself  from  her  divorced  husband  in  the  far  West,  and  could  not  be 
compelled  to  attend  or  obtained  as  a  witness  without  great  expense.  The 
jilaintiff  told  a  story  based  on  his  confused  recollection  of  events,  and 
deliberately  false  in  some  parts,  which  was  contradicted  by  the  defend- 
ants, who  offered  to  put  in  as  the  basis  of  their  certificate  infoi-mation 
received  upon  '  due  inquiry,'  as  well  as  the  result  of  personal  examina- 
tion. This  hearsay  testimony,  though  required  by  law  as  part  of  the 
foundation  of  the  certificate,  was  not  admitted  in  its  support  at  this  time, 
and  the  wife  being  absent  essential  facts  were  kept  out  of  e^•idence.  The 
rulings  of  Judge  Endicott  were  in  every  other  way  favorable  to  the  de- 
fendants. The  jury  disagreed,  as  the  foreman  afterward  stated  to  Major 
Jones,  by  permission  of  the  court — nine  for  the  defendants  and  three  for 
the  plaintiff,  on  the  question  of  '  lack  of  due  inquiry '  only.  Xo  suspicion 
of  a  conspiracy  was  entertained  by  any  juryman. 

"  The  case  was  again  called  last  spring,  the  wife  still  being  absent. 
The  plaintiff,  with  one  or  two  unimpoi'tant  exceptions,  was  his  own  ^vit- 
ness,  and  made  the  same  or  similar  false  statements  as  before,  showing 

*  Plaintiff  filed  a  bill  for  divovec,  cliai'giu<]:  halntual  dnuikeuness.  There  was  proof 
of  the  excessive  use  of  morphine  liy  hypodermic  injection,  on  AThich  the  charire  of 
drunkenness  was  based.  The  bill  was  dismissed,  and  the  Supreme  Court  affirmed  the 
judgment.  After  reviewing  the  various  definitions  of  the  word  ■'  drunkenness  "  tlie 
court  said :  "  It  cannot  be  held  to  include  intoxication  produced  by  the  hypodermic 
administration  of  morphine." 


154  -4   SYSTEM    OF  LEGAL  MEBICLNE. 

•clearly  on  the  stand  to  medical  observation  the  nnreliable  and  irresponsi- 
ble nature  of  his  mental  operations.  The  case  was  classified  as  dipso- 
mania on  all  the  certificates  offered,  of  which  there  were  three.  The 
following  is  a  brief  sketch  of  the  plaintiff's  history : 

"  At  the  time  of  the  trial  he  was  a  man  about  forty  years  of  age,  of 
evidently  neurotic  constitution,  impulsive,  excitable,  with  a  loose  way  of 
expressing  himself,  said  to  have  been  characteristic  of  hiin  from  youth. 
One  witness  testified  that  he  had  always  been  given  to  telling  untruthful 
and  inconsistent  stories.  He  was  reported  to  have  had  an  aunt  who  was 
insane.  His  father  was  a  clergyman,  and  both  his  parents  died  in  his 
early  youth  of  consumption,  leaving  him  in  charge  of  his  relatives.  He 
was  a  bad  and  irregidar  scholar,  though  quick-witted  enough  for  mis- 
chief. At  the  age  of  puberty  he  showed  a  proneness  to  premature  vicious 
conduct  of  various  kinds.  He  is  said  to  have  begun  to  di-ink  by  sprees 
at  the  age  of  fifteen  years.  He  had  some  good  traits  and  impulses,  but 
was  earty  the  slave  of  his  appetites,  and  was  cursed  with  a  craving  for 
drink.  His  sister  says  he  was  a  good  brother  when  sober,  but  a  '  perfect 
devil'  when  di'unk. 

''  He  was  in  frequent  trouble  on  account  of  his  scrapes,  both  in  the 
country  and  in  Boston,  until  the  war  broke  out,  when  he  enlisted.  Hav- 
ing previously  lost  the  sight  of  one  eye,  it  was  still  further  injured  by  a 
thorn,  and  was  enucleated.  He  was  then  put  on  an  army  freight-train 
as  conductor  or  brakeman,  and  continued  to  serve  until  the  close  of  the 
war.  After  the  war  he  was  employed  on  railroads  at  the  West,  leading 
a  life  of  active  dissipation,  according  to  his  own  admission  to  a  witness. 
In  1875  he  came  to  Boston,  claiming  to  have  reformed,  and  that  he  was 
the  possessor  of  a  large  sum  of  money.  In  this  belief  a  widow  of  the 
former  proprietor  of  certain  Turkish  baths  in  Boston — herself  being  the 
owner  at  that  time — married  him.  His  fortune  proved  mythical,  and  his 
wife  was  obliged  to  pay  for  his  wedding-suit  and  for  the  wedding-jom-- 
ney;  she  gave  him  a  gold  watch,  and  supported  him  ever  afterward, 
except  for  the  small  value  of  his  services  in  the  baths.  He  obtained 
control  of  all  her  property,  and  in  a  very  short  time  developed  a  tendency 
to  drink  by  sprees,  in  which  he  was  ugly,  viok^ut,  and  dangerous,  threat- 
ening his  wife  in  particular.  He  was  seldom  seen  drunk  in  the  ordinary 
way,  but  was  exalted  and  maniacal,  acting  more  or  less  automatically, 
and  failing  to  remember  his  conduct  and  conversation  afterward.  It  is 
but  charitable  to  suppose  that  this  accounted  for  his  wholesale  denial  of 
numerous  facts  testified  to  by  a  score  of  witnesses  on  the  stand.  In  a 
year  or  two  he  had  spent  all  his  wife's  property  and  destroyed  her  busi- 
ness by  his  drunken  conduct. 

"  My  attention  was  first  called  to  him  October  12,  1875,  by  Dr.  A.  N. 
Blodgett,  his  wife's  physician,  but  not  related  to  either  party.  Dr.  Blod- 
gett,  being  in  attendance  on  the  wife,  found  the  husband  in  a  state  of 
dehrium  from  drink,  in  which  hallucinations  of  snakes  in  his  bed  were 
prominent.  He  thought  he  saw  the  devil  in  the  looking-glass ;  threat- 
ened to  kill  his  wife  ;  threw  furniture  violently  about  the  room ;  and  did 
not  recognize  Dr.  Blodgett,  but  violently  assaulted  him  several  times. 
Policemen  were  called,  and  he  was  taken  to  the  Tombs.  The  next  morn- 
ing application  was  made  by  Dr.  Blodgett  to  the  Board  of  Directors  for 
Public  Institutions  for  his  commitment  to  Taunton  as  insane.  Having 
learned  his  previous  history,  I  agreed  that  he  might  be  a  dipsomaniac, 


IXSAXITY  IX  ITS  MEDICO-LFJiAL    liEAIUXGS.  I55 

but,  tlie  present  attack  resembling  in  some  of  its  features  delirium  tre- 
mens, advised  that  lie  shoidd  be  sent  to  Deer  Island.  He  did  not  have  a 
perfect  attack  of  that  disease,  and  was  discharged  in  two  or  three  days, 
apparently  rational. 

''  He  was  again  arrested  January  31,  1876,  for  violent  conduct  while 
drunk,  and  released  on  promise  of  good  behavior,  but  was  rearrested  the 
same  day,  fined  three  dollars  and  costs  for  being  di-uuk,  ten  dollars  and 
costs  for  assault  on  a  female  employed  at  the  baths,  and  was  bound  over 
for  six  months  to  keep  the  peace.  He  was  sent  to  jail,  and  Major  Jones,  as 
bail  commissioner,  signed  the  bond  on  which  he  was  released.  June  24, 
187(),  he  was  arrested  again,  but  let  off  on  promise  of  good  beha\'ior.  xVgaiii, 
on  November  8,  1876,  he  was  arrested  as  insane.  Complaint  having 
previously  been  made  to  the  board  of  directors,  I  was  sent  with  Dr. 
Youngman  to  interview  Blodgett.  I  learned  that  he  had  been  very  vio- 
lent at  the  baths,  smasliiug  up  fui'niture  and  fi-ightening  leathers  and 
employees.  I  found  him  at  home,  an  officer  bringing  him  up  from  the 
cellar,  where  he  had  retreated,  having  an  ax  in  his  hand.  His  wife  had 
fled  from  the  house,  and  the  other  inmates  were  locked  in  their  rooms. 
He  was  in  a  very  ugly,  sullen  mood,  ha\'ing  been  di-inking  hea\'ily.  He 
denied,  as  was  his  custom,  ever  drinking  to  excess  or  using  violence  to 
any  one.  He  had  recently  had  a  spasm  of  religious  interest ;  went  inta 
a  prayer-meeting  at  the  Young  Men's  Christian  Association  and  offered 
any  brother  twenty-five  dollars  to  convert  him.  A  member  went  home 
and  prayed  with  liim,  but  was  tiu-ned  out  by  Blodgett  because  he  '  didn't 
pray  worth  a  damned  cent ' !  No  sign  of  delirium  tremens  was  present 
at  this  time,  and  it  was  determined  to  send  him  to  Taunton  as  a  dipso- 
maniac, with  a  view  to  a  sufficiently  long  detention  for  his  improvement 
or  cure.  He  made  no  objection  and  asked  for  no  hearing,  thus  acquies- 
cing in  his  commitment. 

"  Having  remained  at  Taunton  a  few  weeks,  he  was  discharged  on. 
application  of  his  counsel,  Mr.  Towne,  and  was  sober  and  well  behaved 
for  a  considei-able  period  after  it.  He  admitted,  in  an  interview  with 
Major  Jones,  his  irresistible  disposition  to  drink,  and  that  he  presumed 
the  allegations  of  violence  were  true,  but  that  he  did  not  remember  what 
occurred  at  certain  periods  of  his  drinking-speUs.  He  had  also  consulted 
a  relative  in  reference  to  some  cure  for  his  entire  loss  of  self-control  in 
reference  to  drink.  He  joined  the  chm'ch  of  which  his  wife  was  a  mem- 
ber, and  behaved  weU  till  August,  1877.  From  August  to  December  he 
had  three  sprees,  in  which  his  conduct  was  erratic  and  violent.  For  in- 
stance, he  would  rush  down  Washington  Street  in  the  evening  With  a  roll 
of  bills  in  his  hand,  flourishing  them  about,  and  followed  by  a  crowd  of 
men  and  boys.  He  woidd  buy  a  pie,  order  a  hack,  and  send  the  pie  home 
alone  in  the  hack.  On  several  occasions  he  used  vulgar,  profane,  and 
tlu'eatening  language  to  ladies  at  his  wife's  boarding-house.  December 
10,  1877,  complaint  having  been  made  to  the  board  of  directors,  he  was 
examined  at  his  l:)oarding-house  by  Dr.  Youngman  and  myself.  We 
found  him  in  bed,  nervous  and  confused,  as  if  from  a  prolonged  debauch. 
I  talked  with  him  half  an  hour,  explained  to  him  my  theory  of  his  case, 
told  him  I  thought  nothing  but  prolonged  detention  would  do  him  any 
good — that  as  he  had  improved  after  a  few  weeks  in  Taunton,  a  year 
would  do  him  still  more  good.  He  denied  drinking  more  than  wns  good 
for  Imn,  but  said  he  would  stop  at  once  if  we  would  not  certify  in  his 


156  ^   SYSTEM  OF  LEGAL  MEDICINE. 

<3ase.  I  told  liim  if  lie  was  arrested  again  for  violent  conduct  I  should 
certify.  This  interview,  lie  testified,  was  only  a  few  minutes  long,  and 
lie  could  remember  but  one  thing  that  was  said.  Two  days  after,  he  was 
arrested  at  the  baths  for  furious  conduct  toward  his  wife  and  other 
ladies,  and  for  trying  to  kick  over  a  hot  stove.  He  was  sent  to  Taunton 
December  12, 1877,  and  asked  for  no  hearing  at  this  time. 

''  Remaining  in  Taunton  about  three  months  and  a  half,  he  was  dis- 
charged March  26tli,  and  rearrested  for  throwing  a  bottle  at  some  one  at 
the  baths  March  oOtli,  four  days  after.  The  next  morning  he  showed  very 
little  effect  from  liquor  when  seen  at  the  Tombs,  the  period  of  indulgence 
having  been  brief.  He  demanded  a  hearing  at  once,  and  a  certificate  j:)ro 
forma  having  been  signed  to  bring  his  case  before  Judge  McKim,  he  was 
released  on  promising  good  behavior.  In  April  a  libel  for  divorce  was 
filed  by  his  wife,  alleging  brutal  and  violent  conduct,  with  gross  and 
frequent  intoxication.  Blodgett  appeared  in  the  anteroom  of  the  Su- 
preme Court  in  his  usual  peculiar  condition,  insulted  several  ladies  there 
with  obscene  talk,  undertook  to  conduct  his  own  defense,  and  harangued 
the  court  in  such  strange  and  familiar  language  that  the  judge  told  him 
he  must  be  either  drunk  or  crazy,  and  granted  the  divorce.  His  wife 
then  left  him  for  the  West,  in  a  penniless  condition,  and  he  soon  found 
a  lawyer  willing  to  take  his  suit  against  the  alleged  conspirators.  This 
idea  of  a  conspiracy  was,  I  think,  in  part  a  vague  delusion  growing  out 
of  imaginary  wrongs,  and  in  part  a  foolish  attempt  to  rehabilitate  his 
fortunes  and  revenge  himself  at  the  same  time  by  a  suit  against  his 
assumed  enemies.  A  few  weeks  before  the  final  trial  he  was  arrested  for 
drunkenness  in  Waltliam,  and  boasted,  in  his  loose  way,  of  the  immense 
business  he  was  doing,  and  the  money  he  was  going  to  make  out  of  the 
doctors. 

"At  the  last  trial  before  Judge  Lord  the  preceding  facts  and  many 
others  of  similar  import  were  proved.  Twenty  policemen  testified  to 
Blodgett's  habits  of  drunkenness,  eccentricity,  and  to  his  violent  actions. 
They  all  agreed  that  he  was  different  from  ordinary  drunkards  in  his 
talk  and  conduct,  and  was  regarded  as  crazy  and  dangerous  when  in 
liquor.  This  opinion  was  sustained  by  many  sober  witnesses  who  knew 
him  well,  and  by  his  own  confessions  to  Major  Jones,  as  well  as  his  ap- 
pearance on  the  stand.  He  there  denied  in  a  wholesale  way  all  excessive 
drinking  and  all  acts  of  violence,  only  to  be  contradicted  by  many  relia- 
ble witnesses.  He  might,  perhaps,  truly  have  said  that  he  remembered 
no  acts  of  violence,  as  I  have  no  doubt  his  conduct  was  automatic.  Judge 
Lord  allowed  the  facts  obtained  by  '  due  inquiry '  to  be  testified  to  in  full, 
the  other  side  failing  to  object. 

"A  number  of  experts  were  called  by  the  defense.  Drs.  "Walker, 
Brown,  Gage,  Russell,  Denny,  Jelly,  Folsom,  Channing,  Day,  Blodgett, 
Fisher,  and  Youngman  gave  their  definitions  of  dipsomania  and  testified 
to  the  propriety  of  treating  it  in  hospitals  for  the  insane,  in  the  absence 
of  other  special  institutions.  These  gentlemen  substantially  agreed  in 
affirming  the  existence  of  such  a  disease,  and  in  the  necessity  of  so  treat- 
ing it. 

"  The  plaintiff  called  on  his  behalf  Drs.  Henry  G.  Clark,  J.  P.  Tread- 
well,  and  Horace  Chase.  Dr.  Clark  thought  a  dipsomaniac  must  be  a 
person  who  on  drinking  a  single  glass  must  inevitahly  go  on  to  complete 
intoxication.     He  thought  Bloda-ett  did  not  fall  within  this  definition. 


INSANITY  IN  ITS  MEDICO-LEGAL   BEAMINGS.  107 

He  was  oljlig-cd  to  admit,  however,  tliat  he  liad  recently  said  that  Bh)dgett 
Avas  'crazy  drunk'  and  ])roi)erly  sent  to  Taunton,  but  was  k(^pt  too  lon^; 
iind  that  he  had  certilicd  witliin  three  months  in  the  case  of  a  dan<^erous 
dipsomaniac  committed  to  Danvers.  Dr.  Treadwell  gave  his  views  at 
length,  and  thought  the  part  of  the  testimony  he  had  heard  did  not 
warrant  calling  Blodgett  a  dipsomaniac.  Dr.  Chase's  testimony  I  did 
not  hear. 

"Judge  Lord's  charge  to  the  jury  was  satisfactory  in  every  way  to 
the  defense,  and  was  an  admiraljle  statement  of  the  rights  and  liabilities 
of  physicians  certifying  in  cases  of  insanity.  It  deserves  reproduction 
as  a  whole,  l)ut  I  will  give  only  a  very  brief  abstract  of  it.  Judge  Endi- 
<;ott  had  said  in  substance  at  the  previous  trial  that  it  was  evident  from 
the  testinu>ny  that  there  was  such  a  disease  as  dipsomania ;  that  the  line 
between  it  and  ordinary  vicious  drinking  was  a  narrow  one,  which  only 
qualified  medical  men  could  safely  draw ;  and  that  a  lunatic  hospital  was 
a  proper  place  for  its  treatment.  Judge  Lord,  however,  told  the  jury  to 
reject  the  technicalities  of  the  doctors,  and  charged  that  if  mental  un- 
soundness of  any  kind  existed  it  was  an  end  of  the  case ;  that  if  physi- 
cians honestly  believed  the  party  to  be  insane,  although  they  may  have 
been  misled  or  mistaken,  they  were  not  responsible.  They  were  obliged 
by  law  to  make  '  due  inquiry '  of  the  parties  most  likely  to  possess  the 
facts  relating  to  insanity,  and  nearest  b}'-  ties  of  relationship  or  affection 
to  the  patient;  but  they  could  not  take  sworn  CA-idence  in  the  case,  and 
must  act  according  to  their  best  judgment  upon  the  facts  obtainable. 
Their  certificate  was  not  required  by  law  to  be  under  oath,  and  was 
merely  the  necessary  means  of  bringing  the  case  into  the  jurisdiction  of 
the  proper  court,  after  which  they  were  not  responsible  for  the  action  of 
the  court,  unless  it  could  he  shown  that  they  willfully  gave  false  testi- 
mony, or  grossly  and  criminally  neglected  to  in([uire  into  the  facts  of  th.e 
€ase.  In  the  words  of  the  court :  '  If  capable  physicians  should  act  reck- 
lessly, disregarding  the  rights  of  the  part}-,  and  send  him  off  to  a  hospital 
without  any  evidence  at  aU,  then  they  would  be  responsible.  But  if  on 
the  other  hand  they  made  the  inquiry  which  the  circumstances  of  the 
particular  case  called  for,  then,  although  subsequent  events  raiw  show 
that  that  inquiry  might  have  been  pursued  further  if  they  acted  in  good 
faith,  that  is  theii"  protection.  The  jury  rendered  a  verdict  for  the  de- 
fendants." 

The  same  questions  here  arise  regarding  the  execution  of  legal  papers 
as  do  where  there  is  no  toxic  causation  of  the  unsoundness,  and  the  issues 
are  varied  and  alwaj-s  interesting. 

The  case  of  0' Conner  vs.  Rempt,  29  N.  J.  Eq.  156,  is  one  of  a  familiar 
kind  where  undue  influence  was  evidently  exerted.  This  was  a  biU  t(^ 
set  aside  a  deed  alleged  to  have  been  executed  while  the  plaintiff  was  in- 
toxicated and  in  a  state  of  mental  aberration.  The  ])laintiff  lodged  at 
the  house  of  the  defendants  on  March  2,  1877.  He  had  never  met  Mrs. 
Rempt,  the  grantee,  before.  He  returned  on  the  4th  of  ]\[arch  and  from 
that  time  until  the  7th  was  secluded  by  them  from  his  friends.  He  was 
drunk  when  he  returned  on  the  4th,  had  been  on  a  drunken  debauch  for 
a  month  previously,  and  was  delirious  when  he  left  his  home.  The  de- 
fendants admitted  that  O'Conner  was  not  sober  when  he  came  to  them, 
and  i\\ej  allowed  him  to  ^{ny.  The  next  morning  he  was  sick,  and  was 
told  to  go  to  a  hospital,  but  he  asked  to  be  allowed  to  remain,  saying, 


158  ^   SYSTEM  OF  LEGAL  2LEDLCTXE. 

''Toa  let  me  stay,  aud  I  Avill  give  jou  all  my  i^roperty,  and  you  can 
take  care  of  me  as  long  as  I  live.  I  ^vlll  make  it  all  right."  On  March 
7th  the  deed  was  executed,  after  three  pre\'ious  attempts  to  obtain  his 
.signatiu-e  to  it  had  failed,  o^ving  to  the  fact  that  he  was  in  a  stupor. 
The  deed  was  recorded  on  March  8th,  and  a  few  days  afterward  he  wa& 
removed  fi'oni  the  defendants'  house  by  the  police,  in  a  state  of  mental 
and  physical  prostration.  On  March  19th  this  bill  was  filed.  The  Court 
of  Chancery  declared  the  deed  void,  on  the  ground  that  "when  the  com- 
plainant went  to  tlie  house  of  the  defendants  his  mind  was  disordered ; 
that  the  day  before  the  deed  was  executed  he  was  all  day  in  a  state  of 
ch'unken  insensibility :  and  that  when  he  was  rescued  from  the  custody 
of  the  defendants  he  was  suffering  from  dehrium  ti-emens."  The  case  of 
Bliss  vs.  Conn,  d:  Pas.  Eivfrs  E.  R.  Co.,  24  Vt.  424,  is  one  in  which  the 
question  of  time-limit  arose,  and  where  the  action  of  the  Supreme  Court 
was  exti'cmely  merciful  and  j)i'otecting.  The  defendants  took  lands  of 
the  plaintiff  for  theu'  use,  and  an  award  was  made.  Under  the  Vermont 
statute  then  in  force  (1852)  an  appeal  from  an  award  must  be' made 
within  ninetv"  days,  except  where  disabilities  exist,  when  the  appeal  must 
be  made  -within  ninety  days  fi-om  the  removal  of  the  disabilities,  which 
are  in  the  cases  of  ''married  women,  infants,  idiots,  or  insane."  The 
plaintiff  for  a  long  time  was  intemj^erate  to  such  an  extent  as  to  unfit 
him  for  business,  was  out  of  Ms  mind,  required  close  watching,  thi-eatened 
to  injui'e  others,  burn  his  buildings,  etc. ;  and  dui'ing  the  time  the  land 
was  taken  and  the  award  was  made,  his  family  tried  to  talk  with  him 
about  the  matter,  but  were  unable  to  make  him  understand  it  until  the 
ninetv^  days  had  expii*ed.  Afterward  with  his  consent  the  appeal  was 
made,  and  was  dismissed  by  the  County  Coiu't  on  the  ground  that  it  had 
not  been  made  within  ninety  days. 

The  plaintiff  then  apiDlied  to  the  Supreme  Court  for  a  ^^n:\t  of  certi- 
orari, which  was  granted,  aud  the  judgment  of  the  County  Coui't  reversed, 
the  coiu't  holding  that  the  plaintiff  was  not  capable  of  managing  his 
affairs,  and  should  be  gi"anted  the  benefits  of  the  pro%ision  of  the  statute 
relating  to  disabilities  of  "insane,"  even  though  his  disability  was  caused 
by  his  own  excesses  and  misconduct. 

The  subsequent  ratification  of  a  contract  alleged  to  have  been  made 
when  the  person  is  intoxicated  has  been  held  to  make  parts  of  the  trans- 
action binding.* 

THE   CAPAaTY   OF   DEAF-]MUTES. 

The  deaf-mute  was  at  one  time  considered  to  be  as  irresponsible  as 
the  idiot,  so  far  as  testimony  was  concerned,  in  coiu'ts  of  law.  How- 
ever, a  much  more  intelligent  view  of  the   question  of  competency 

*  Smith  vs.  WilJinmson,  8  Utah,  219.  This  was  an  action  concerning  a  promissory 
note.  It  appears  that  the  note  was  given,  together  with  a  Holstein  hull,  in  exchange 
for  a  Durham  bull.  A  few  days  afterward  defendant  retiu-ned  the  bull,  and  took  in 
its  place  a  Durham  heifer,  in  pursuance  of  an  agreement  made  at  the  time  of  the 
transaction.  Defendant  pleaded  that  he  was  intoxicated  at  the  time  he  signed  the 
note.  Judgment  was  rendered  for  defendant,  but  the  Supreme  Coiu-t  reversed  the 
judgment  on  the  ground  that  even  though  defendant  was  intoxicated  at  the  time 
the  note  was  signed,  his  subsequent  action  in  exchanging  the  bull  for  the  heifer  and 
still  retaining  the  heifer  was  a  ratification  of  the  transaction,  and  of  his  signature  to 
the  note. 


INSAXITY  IX  ITS  MEDICO-LEGAL   liEJIlIXGS.  159 

is  now  taken,  and  it  is  by  no  means  tlie  rule  because  certain  chan- 
nels of  expression  which  put  the  individual  in  communication  with 
the  world  are  cut  off,  that  he  is  entirely  deprived  of  intellig-ence.  The 
law  is  disposed  to  approve  of  the  actions  of  persons  of  this  kind, 
provided  they  are  in  no  other  way  mentally  incapacitated.  The  mere 
deprivation  of  the  senses  of  hearing,  sight,  and  speech  does  not  hiiply 
weak-mindedness,  althougli  under  the  English  law  a  deaf-mute  is  incom- 
petent to  give  evidence  if  he  is  also  blind.  Disputed  wills  (Jarm.,  Wills, 
uth  Am.  ed.,  chap,  iii.)  of  deaf-mutes  have  been  allowed  to  stand.  Those 
who  offer  such  a  Avill  for  probate  must  prove  the  intelligence  and  abil- 
ity that  constitute  testamentary  capacity.  Judge  Redfield  has  decided 
that  educated  deaf-mutes  who  make  holographic  wills  or  convey  by  gest- 
ures their  intentions  and  wishes  should  l3e  allowed  to  do  so,  and  that 
such  wills  should  stand.  The  affliction  of  coincident  blindness  need  not 
necessarily  change  the  situation.  It  is,  however,  necessaiy  to  differentiate 
the  mutis'm  of  simple  accidental  deprivation  or  uncomphcated  origin 
from  that  which  is  a  feature  of  imbecility.  This  question  arises  not  only 
in  will-making,  but  where  contracts  of  any  kind  are  entered  into. 

Dr.  Peet,  who  has  had  very  wide  experience  with  the  deaf  and  dumb, 
gives  the  following  general  principles  in  regard  to  their  rights  and 
responsibilities : 

"A  deaf-mute  who  has  no  knowledge  whatever  of  wi'itten  languages 
may  yet,  if  his  dialect  of  gestures  is  sufficiently  copious  and  precise, 
possess  the  intelligence  necessary  to  manage  his  own  affairs,  to  make  all 
civil  contracts,  to  execute  a  deed  or  a  will,  or  to  give  evidence  in  a  court 
of  justice.  But  as  the  degi-ee  of  intelligence  and  of  moral  development 
in  uneducated  mutes  is  very  various,  some  who  have  been  neglected  in 
infancy  being  but  a  step  above  idiots,  they  should  be  carefully  examined 
to  ascertain  whether  they  really  possess  the  necessary  degree  of  knowl- 
edge and  intelligent  will.  With  respect  to  the  formalities  used,  it  may 
be  laid  down  as  a  general  rule  that  the  deaf-mute  who  can  read  and 
write  but  imperfectly  or  not  at  all  should  be  regarded  as  in  the  position 
of  a  German  or  Frenchman  whose  ignorance  of  our  language  necessi- 
tates the  employment  of  a  sworn  interpreter  between  him  and  the  court. 
But  when  the  \leaf-mute  can  read  and  write  well  the  best  mode  is 
that  prescribed  in  the  French  Code.  In  the  case  of  such,  reading  supplies 
hearing  and  writing  supplies  speech.  Hence  it  folloAvs  that  a  paper  pre- 
sented to  a  well-instructed  deaf  person,  calling  his  attention  by  pointing 
with  the  finger  to  the  writing,  should  be  considered  as  read  to  him,  it 
being  understood,  of  course,  that  there  should  be  sufficient  light  and 
sufficient  legibility  of  writing.  We  think,  however,  it  ought  to  be 
specially  enacted  that  a  legal  service,  in  the  case  of  such  persons,  should 
consist  in  giving  them  a  copy  of  the  writ  or  notice  to  be  served,  inform- 
ing them  in  writing  of  its  nature  and  contents:  and  in  the  case  of  deaf- 
mutes  who  cannot  read,  or  l)ut  hnperfectly,  the  reading  may  be  accom- 
pHshed  by  the  aid  of  a  competent  interpreter.  Any  legal  oath  or  obligation 
may  lie  taken  or  assumed  by  a  well-instructed  deaf  person  by  writing  out 
with  his  own  hand  the  formula  before  witnesses,  with  such  fornis  of 
solemnity  as  the  occasion  nuiy  demand,  or  by  a  conversation  in  writing 
with  the  officiating  magistrate." 

There  can  be  no  question  as  to  the  right  of  the  deaf-mute  to  the  ser- 
vices of  a  competent  interpreter. 


160 


A   SYSTEM  OF  LEGAL  MEDLCLNE. 


The  matter  of  accident  cases  resulting  in  traumatic  insanity  has  not 
been  here  considered,  but  the  reader  is  referred  to  subsequent  articles 
'hj  Dr.  Dana  and  Mr.  Godkin  which  cover  the  ground  both  as  to  the 
medical  and  legal  jDoints. 


BIBLIOGEAPHY 


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and  others  are  suggested  for  the  aid  of  the  reader. 


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Dwight  Case.      "Chicago  M.  J.  and  Exam.,"  vol.  xhiii.,  pp.  574-583. 
1884.   (197)   Tebaldi,    A.,     "  Fisionomia    ed    Expressione    nelle    Loro    Deviazioni." 

Yerona  and  Padua. 
1884.  (198)  Cloiisfon.  T.  S.,  "The  Position  of  the  Med.  Prof,  in  Regard  to  Certificates 

of   ^Mental   Unsoundness,"   etc.     "Edinb.    Med.    J.,"   vol.    xxx.,  pp. 

889-908. 
1884.  (199)  Savage,  ^'.  77.,  "Insanity  and  Allied  Neuroses,"  etc.     London. 


166  ^   SYSTEM  OF  LEGAL  MEDLCIXE. 

1884.  (200)  S.  C.  Wood,  "  The  La^  of  LiPanity."     Absurdity  of  the  present  system 

illustrated  in  the  Tavlor  Case  (abstr.).     "PolvcKnic/'  Philadelphia, 
1884-8,  vol.  ii. 
1884-85.  (201)  CuUhigworth,  C.  J.,   '-Action  for  Alleged  "Wrongful  Detention  in  an 
Asylum."     "Med.  Chi-on.,"  vol.  i.,  pp.  227-230,  Manchester. 

1885.  (202)  Ball.  " La  Morphinomanie.     Les  Frontieres  de  la  Folic."  etc.      Paris. 
1885.   (203)  Sa.ro.ffe.  G.  H.,  "  Oiu'  Duties  in  Eeferenee  to  the  Signing  of  Lunacy  Cer- 
tificates."    '-Brit.  M.  J.."  vol.  i..  p.  692. 

1885.  (204)  Peeters,  "L'Alcool  Physiologic,  Pathologic.  Medecine  Legale."   Bru^eUes. 

1886.  (205)  Fatterson,    E.,     '•'  Monomania     as     Affecting    Testamentarr    Capacity." 

Papers  Med.-Leg.  See.  X.  Y.,''  1886,  pp.  421-i40. 
1886.   (206)  Brismud,  E.,  ' •  L'Hypnotisme  et  les  Etats  Analogues  au  Point  de  Vue 

Medico-Legale."'    "  Gaz.  Hebd.  de  Med.,"  Paris,  1886,  2.  s.,  vol.  xxiii., 

pp.  859-862. 
1886.  (207)  Ireland,  "The  Blot  on  the  Brain,"  etc.     New  York. 
1886.  (208)  Legrand  du   Saidle,  H.,   "  Traite   de  Medecine  Legale  de  Juiisprudence 

Medical  et  de  Toxicologic,"  2d  ed.    Paris. 

1886.  (209)   Tibert,  "  Precis  de  Medeciue  Legale."     Paris. 

1887.  (210)  EmminyJaus,  "Die  Psychosen  Storungen  im  Kindesalter."     Tubingen. 
1887.  (211)  Soyes.  TV..  "The  Medico-Legal  Aspects  of  Hypnotism."     "  Science,"  New 

York,  1887,  vol.  ix.,  p.  220. 
1887.  (212)   Von     Kraft-Ehing,     "'  Yersuchter     Giftmord ;     Paranoia    perseeutoria." 

"  Friederich's  Bl.  f.  gerichtl.  Med.."  Kiu-nb.,  1887,  vol.  xxxviii.,  pp. 

186-196. 
188?.  (213)  2fesnet,  "  Etude  Medico-Legale  siu"  le  Somnambulisme  Spontane  et  le  Som- 

nambulisme  Provoque."      "'  Gaz.  d.  Hop.,"  Par.,  1887,  vol.  Ix.,  pp. 

306-308. 
1887.   (214)  Ireland.  '' On  Idioev  and  Imbecilitv."    London. 
1887.  (215)  Earle,  ''The  Cm-ability  of  Insanity,"  etc.     Philadelphia. 
1887.  (216)  Clevenger,  S.    V.,   "The  Medical  Jm-isprudence  of  Mental  and  Nervous 

Diseases."     "J.  Am.  M.  Ass.,"  Chicago,  vol.  ix.,  pp.  612-614. 

1887.  (217)  Lafforgue,  Jean  X.  F.,  "Contribution  a  I'Etude  Medico-Legale  de  I'Hjtj- 

notisme."     Bordeaux.     No.  27,  p.  84. 

1888.  (218)  Luys,  "Questions   Medic o-Legales   Afierentes   a  THypnotisme."     "  Gaz. 

d.  Hop.."  Par.,  1888,  vol.  lix..  pp.  677-680. 
1888.  (219)  Kerr,  "Inebrietv,"  etc.     Philadelphia. 

1888.  (220)  Janet,  "  L'Automatisme  Psychologique."     Paris. 

1889.  (221)  Bernheim,  "  Suggestive  Therapeutics,"  etc.     Translated  by  C.  A.  Herter. 

New  York. 
1888-89.  (222)  Fisher,  T.  W.,  "Paranoia  in  Belation  to  HallucLuations  of  Hearing," 

with  two  cases  of  medico-legal  interest.     "Am.  J.  Insan.."  1888- 

1889,  vol.  xlv.,  pp.  18-31. 
1889.  (223)   Von   Krafft-Ebing,    "Betrug;    moralisehes   Irresein;   Hystero-Epilepsie ; 

geriehtsarztliches  Gutachten."    "Friederich's  Bl.  f.  gerichtl.  Med.," 

Niirnb.,  1889,  vol.  xL,  pp.  81-95. 
1889.  (224)   Von   Krafft-Ebing,    Mordversuch ;   Paranoia   perseeutoria ;    geriehtsarzt- 
liches Gutachten,"  ibid.,  pp.  95-99. 
1889.  (225)   Von   Kraft-Ebing,    "  Betrug ;    Ehrenbeleidigimg :    Paranoia    querulans ; 

geriehtsarztliches  Gutachten,"'  ibid.,  pp.  169-175. 
1889.  (226)  ilaraudon  de  Montyel,  E..    "De  la  Dissimiilation  en  Alienation  Mentale  et 

de  son  Importance  Medico-Legale."    "Ann.  d'Hyg.,"  Par.,  1889,  3.  s., 

pp.  526-.546. 
1889.  (227)  Siegeri.^,  "  Kapports  de  la  Suggestion  et  du  Somnambulisme  avec  la  Juris- 

pi-udence  et  la  Medecine  Legale."     "  Tribime  Med.,"  1889,  2.  s.,  vol. 

xxi.,  p.  523. 
1889.   (228)  Xoye.i;  "Paranoia,"  etc.     "Am.  Jour,  of  Psych.,"  May,  1889. 

1889.  (229)  Xoyes,  "Clinical  History  and  Autopsy  of  a  Case  of" General  Paresis  of 

Nine  Years'  Diu'ation."     "Journal  of  Nervous  and  Mental  Diseases," 
August,  1889. 

1890.  (230)   W.  Sevan  Lein.%  "A  Text-book  of  Mental  Diseases."  with  special  refer- 

ence to  the  pathological  aspects  of  insanitv.     Philadelphia. 

1890.  (231)  Coonibes-Kiapp,   "The   Insanity  of  Doubt."  '"Am.   Jour.  Psychology," 

January,  1890. 

1891.  (232)  T.  S.  Clon-ston,  "  The  Neuroses  of  Development :  being  the  Morison  Lect- 

ures for  1890."     Edinbm-gh. 


INDEX.  1G7 

1891.  (233)  Coiules,  "  Neurasthenia  and  its  Mental  Symptoms."     The  Shattuck  Lect- 

ures, 1891.     Boston. 

1892.  (234)  Havdock-KUis,  "  The  Criminal."     Loudon. 

1893.  (235)  Kirchhojf,    "Handljook  of    Insanity    for    Practitioners    and    Students." 

American  Translation.     New  York. 
1893.  (23G)  H.  P.  Stearns,  "Lectures  on  Mental  Diseases,"  etc.     Philadelphia. 

1893.  (237)   "Entscheidungen  des  Keiehsgerichts  in  Civilsaeheu."     Leipzig. 

1894.  (238)  Bkjal,  "De  la  Folie  par  Commotion  Cerebrale,"  etc.     "  Annales  d'Hygifene 

Publique,"  etc.     3.  s.,  t.  31,  Nos.  iii.  and  iv. 
1S94.  (239)  M.  J.  Vomn,  "Conformation  des  Organes  Genitaux  chez  les  Idiots,"  etc. 
"Annales  d'Hygiene,"  etc.,  Juin,  p.  52.5. 
Also  consult  "Journal   du   Palais";    "Annales   d'Hygiene,"   etc.;  Code    Civile; 
"  Eutscheidungen  des  Reiehsgeriehts    in    Civilsachen  "  ;    "  American 
and  English  Law  Encyclopedia,"  for  eases  and  decisions. 


INDEX. 

General  Works  and  Articles  npon  Insanity  and  its  Jurisjyrndence:  1,  2,  3,  4,  6,  8,  9,  10, 
11,  12,  14,  16,  20,  21,  23,  24,  26,  28,  29,  30,  31,  33,  34,  39,  48,  51,  52,  53,  54,  64,  6.5, 
66,  67,  68,  75,  77,  79,  81,  85,  88,  90.  91,  94,  95,  96.  98,  99,  100,  104,  109,  110,  HI, 
120,  122,  124,  125,  128,  129,  131,  133,  136,  138,  139,  146,  151,  1-52,  1.54,  159,  162, 
167,  168,  171,  172,  173,  174,  176,  178,  179,  180,  185,  186,  187,  189,  190,  191,  192, 
199,  208,  209,  216,  235,  236. 

Symptomatologi/  and  Biai/nosis  :  42,  43,  44,  45,  47,  49,' 60,  69,  81,  97,  105,  110,  113, 
127,  vols,  iii.,  iv.,  vi!,  136,  142,  149,  172,  175,  184,  188,  191,  192,  195,  202,  205, 
214,  219,  222,  231. 

Prevention  and  Cure  :  5,  215. 

Craniologij:  80,  104,  121,  105,  181. 

Paretic  Dementia :  33,  123,  127,  vols,  iii.,  iv.,  v.,  vi.,  135,  163,  170,  196,  229. 

DelHsions :  45,  175. 

Lmid  Intervals  and  " Partial  Insanity"  :  7,  41,  74. 

Writing  of  the  Insane  :  82,  115. 

Deaf-nintes,  etc  :  13. 

Expert  Tcstinwni/ :  36,  102,  106,  148,  150. 

Interdiction  and  Sequestration  :  17,  38,  59,  78,  130,  141,  155,  198,  203. 

Traumatic  Insanity :  108,  127,  vol.  ii.,  161,  238. 

Cases:  18,  35,  57,  70,  104,  112,  116,  160,  166,  169,  200,  201,  237. 

Ecsponsihility :  86,  89,  92,  93,  118,  132,  137,  143,  158,  164,  183,  193. 

Commissions :  19,  35,  40,  58,  62,  72,  114,  182. 

General  Leqislation :  84,  156,  157,  194,  200. 

Simulated  insanity :  21,  22,  50,  101,  103,  140,  144,  160,  226. 

Pathology :  56,  61,  71,  85,  107,  119,  127,  vols,  ii.,  iii.,  v.,  134,  145,  180,  223,  234,  236. 

Etiolo(/>/ :  25. 

"  2Ioral  Insanity  "  :  26,  30,  98,  125,  147,  223. 

Phiisio(inomi/ :  27,  55,  73,  189,  197. 

Classification  and  Vital  Statistics:  32,  37,  46,  47,  63,  76,  83,  87,  117,  153,  215. 

Evidotce  of  tlic  I)isane  :  126,  177. 

Tlic  Insane  Ear  :  127,  vol.  v. 

Alcohol,  Morphine,  etc.  :  202,  204,  219. 

Idiocy  and  Imhecility  :  207,  214,  232,  239. 

Insanity  of  Children  :  210. 

Hi/pnotism  and  Somnambulism:  206,  211,  213,  217,  218,  220,  221,  227. 

Paranoia :  205,  212,  214,  222,  224,  225,  228. 

Xcurastlieniu :  233. 


MENTAL  RESPONSIBILITY  OF  THE  INSANE  IN  CIVIL 

CASES. 

BY 

CALVIN  E.  PRATT,  Justice  of  N.  Y.  Supreme  Court. 


Insanity  is  the  generic  term  which  includes  lunacy,  derangement, 
mania,  frenzy,  madness,  delirium,  alienation,  aberration,  dementia,  and 
monomania ;  each  of  these  terms  has  a  well-known  definition,  and  each 
form  of  mental  disease  has  its  well-marked  symptoms  and  characteris- 
tics. No  definition  of  insanity  is  entirely  satisfactory  to  all  lawj-ers  or 
doctors,  or  seems  to  cover  all  cases  that  can  arise.  Cases  of  what  is 
called  emotional  insanity,  morbid  and  irresistible  impulse,  hj-pnotism, 
epilepsy,  moral  insanity,  and  various  abnormal  mental  manifestations 
that  occur,  or  are  claimed  to  occur,  make  it  difficult  to  construct  a  short 
and  simple  definition  fit  for  practical  and  universal  use  in  coui-ts  of  jus- 
tice. Perhaps  as  satisfactory  a  definition  as  can  be  given  in  a  patholog- 
ical sense  is  that  of  Dr.  Hammond :  ''  That  person  is  insane  whose 
mental  processes  are  directly  at  variance  with  those  of  the  average 
human  mind."  This  is  a  medical  definition.  In  laAv,  however,  the  ques- 
tion is  not  whether  insanity  exists  in  a  medical  sense,  but  whether  there 
exists  that  liind  and  degree  of  aberration  of  mind  or  incapacity  which  will 
shield  a  person  from  punishment  for  crime,  annul  liis  contracts,  or  set 
aside  his  will. 

It  would  be  interesting  to  trace  the  changing  and  complicated  history 
of  forensic  insanity  from  its  foundation  in  the  Roman  law  to  the  present 
tune.  Such  an  effort  will  involve  a  critical  examination  of  all  the  Eng- 
lish and  American  cases  where  the  subject  has  lieen  judicially  considered, 
and  will  not  aid  much  in  ascertaining  the  legal  relations  of  insanity  at 
this  time.  The  radical  changes  that  have  taken  place  in  the  last  century 
in  regard  to  the  criteria  of  capacity  and  responsibility  in  mental  disease 
might  well  be  termed  a  revolution.  Tliese  are  due  chiefly  to  the  great  prog- 
ress made  by  the  medical  profession  in  the  knowledge  of  diseases  of  the 
mind,  and  their  use  as  experts  in  courts  where  such  issues  were  involved. 
It  is  only  by  a  trial  and  decision  by  a  competent  court  that  a  principle 
of  medical  jurisprudence  can  be  said  to  be  estal^lished,  and  hence  the 
most  recent  decisions  are  to  be  regarded  as  the  true  enunciations  of  the 
principles  by  which  we  are  to  be  guided  in  considering  the  legal  tests  to 
be  applied  in  this  class  of  cases.  It  is  not  necessary  to  allude  to  the  com- 
mon-law definitions  of  insane  persons,  lunatics,  idiots,  non  compos  mentis 
delusions,  illusions,  and  monomaniacs,  as  the  term  unsound  mind  may, 
for  all  practical  purposes,  be  held  to  include  every  species  of  insanity  or 
mental  unsoundness  in  courts  of  ci\-il  jurisdiction. 

1G9 


170  ^   SYSTEM  OF  LEGAL  MEDICINE. 

Cases  invohdng  qnestions  of  unsoundness  of  mind  or  insanity  in 
every  form  are  divided  into  two  classes,  civil  and  criminal :  the  first  is 
one  of  capacity  to  do  a  particular  act  in  question,  siich  as  making  a  con- 
tract or  will ;  the  second  is  one  of  responsibility  for  an  act  or  omission, 
such  as  an  assault  or  homicide.  Perhaps,  as  a  general  rule,  it  may  be 
stated  that,  in  regard  to  contracts  generally  and  testamentary  capacity, 
no  man  is  regarded  as  of  unsound  mind  unless  he  is  "  incapable  of  appre- 
ciating the  nature,  and  forming  a  rational  judgment  upon  the  results,  of 
the  particular  act  which  is  the  subject  of  judicial  consideration."  No 
such  general  rule  can  be  stated  as  apjjlicable  to  capacity  and  liability  of 
insane  persons  in  the  criminal  law,  as  the  rule  is  not  uniform  in  England 
or  the  various  States  of  America,  neither  do  the  judges  and  medical  ex- 
perts fully  agree  as  to  a  proper  rule  of  responsibility.  The  rule  in  the 
State  of  New  York  is  in  substance  as  foUows :  "  Was  the  person  whose 
act  is  in  question  laboring  under  such  a  disease  of  the  mind  as  rendered 
him  incapable  of  knowing  the  nature  and  quality  of  the  act  and  that  it 
was  "v\T.^ong?"  There  are  many  distinguished  experts  who  claim,  with 
great  force  of  reason — and  the  principle  has  been  held  by  many  able 
judges — that  another  element  should  be  regarded  as  a  valid  exculpatory 
plea,  to  wit,  loss  of  self-control  from  any  disease  of  the  mind.  The  ride 
would  then  be  stated  as  follows :  ''Was  the  person  whose  act  is  in  ques- 
tion able  to  understand  the  nature  of  the  act  and  pass  a  rational  judg- 
ment on  its  consequences  to  himself  and  others,  and  was  he  a  free  agent 
so  far  as  that  act  was  concerned  ? "  and  such  will  undoubtedly  be  the  rule 
in  the  near  futui'C. 

We  will  now  examine  the  legal  relations  of  insanity  or  unsoundness 
to  certain  specific  issues  relating  to  the  f ollo-vving  subjects :  wills,  eon- 
tracts,  including  contract  of  marriage,  torts,  and  expert  testimony. 

The  medico-legal  issue  in  cases  regarding  wills  is  whether  at  the  time 
of  making  the  will  the  testator  possessed  testamentary  capacity.  The 
rule  upon  this  question  may  be  tersely  stated  as  follows :  "  In  order  to 
make  a  valid  will  a  testator  must  have  sufficient  capacity  to  comprehend 
the  nature  of  the  act  he  is  performing ;  he  must  understand  the  extent 
of  the  X->ropert3''  of  which  he  is  disposing ;  he  must  comprehend  the  rela- 
tion which  he  holds  to  those  who  have  claims  upon  him,  and  be  capable 
of  making  a  rational  selection  among  them."  {Am.  &  Eng.  Encydop(edia 
of  Lmv,  vol.  xi.,  p.  151,  and  cases  there  cited.) 

The  rule  above  cited  is  explained  and  illustrated  by  judges  according 
to  the  facts  and  circumstances  developed  in  each  case  under  considera- 
tion. For  example.  Lord  Cockburn,  in  the  case  of  BanAs  vs.  Goodfellow, 
L.  R.  5  Q.  B.  549,  stated  in  relation  to  the  last  clause  of  the  rule:  "He 
must  be  able  to  comprehend  and  appreciate  the  claims  to  which  he  ought 
to  give  effect,  and,  mth  a  view  to  this  effect,  that  no  disorder  of  the  mind 
shall  poison  the  affection,  pervert  his  sense  of  right,  or  prevent  the  exer- 
cise of  his  natural  faculties;  that  no  insane  delusion  shall  influence  his 
mil  in  disposing  of  his  property,  and  bring  al)out  a  disposal  of  it  which, 
if  the  mind  had  been  sound,  would  not  have  been  made." 

The  burden  of  proof  is  always  upon  the  party  that  propounds  the  will 
for  probate  to  establish  its  validity. 

1.  He  must  prove  that  the  statutory  requirements  have  been  complied 
with. 

2.  That,  by  the  subscribing  witnesses,  the  testator  appeared  to  under- 


MEM'AL  RESPONSIBILITY  OF  THE  INSANE  IN  CIVIL  CASES.      171 

stand  the  business  in  which  he  was  engaged;  hut,  in  ease  the  sub- 
scribing Avitnesses  are  dead  or  cannot  be  produced,  tlie  proponent  of  the 
will  can  rest  upon  the  presumption  that  every  man  is  presumed  to  Vje 
sane  imtil  some  evidence  to  the  contrary' is  offered.  (68  N.  Y,  409,  7 
Pick.  94.)  Where,  however,  a  party  has  been  proved  to  be  insane,  the 
presumption  is  that  it  continues,  and  the  bui-den  then  shifts  to  the  party 
alleging  sanity  {Am.  lO  £»(J-  £iiC!/clopadi(i,  vol.  xi.,  p.  160),  and  he  must 
prove  that  the  will  was  executed  during  a  lu('id  interval. 

It  will  at  once  be  perceived  in  this  class  of  cases  tliat  a  gi'eat  many 
questions  arise  as  to  the  kind  and  degree  of  insanity,  and  how  mucli  in- 
fluence it  had  upon  the  testator  in  the  making  of  the  will.  The  insanity 
may  be  chronic  or  acute,  or  it  may  be  the  result  of  disease  or  accident. 
It  has  been  held  that  extreme  old  age,  excessive  use  of  intoxicating 
liquor,  strong  beliefs,  existence  of  mental  delusions,  licentiousness,  and 
unreasonable  prejudice  against  relatives  are  not  necessarily  incompatible 
with  mental  capacity  or  intelligence  to  make  a  will.  (Same  volume  of 
Am.  tO  UiKj.  Enrydop<edia^  supra,  p.  154,  note,  and  cases  there  cited.)  AU 
of  these  matters  may  be  proved  in  opposition  to  the  probate  of  a  ■vvdll, 
and  the  question  will  be  to  what  extent,  if  any,  they  influenced  the  testa- 
tor in  the  making  of  his  wiU,  or  to  what  extent  the  testator  was  disabled 
by  them  from  complying  with  the  rule  heretofore  stated.  In  this  con- 
nection it  may  be  stated  that  reasonableness  of  the  pro\asions  of  a  will 
is  always  an  element  for  consideration  in  determining  the  question  of 
testamentary  capacit}^ ;  but  the  mere  gi\dug  of  property  to  a  stranger 
rather  than  relatives,  without  more  evidence  of  want  of  testamentary 
capacity,  is  not  sufficient  to  break  a  "wdU.  It  is  alwaj'S  to  be  observed 
that  the  highest  degree  of  mental  soundness  is  not  requii-ed  to  constitute 
capacity  to  make  a  wiU.  "  A  person's  mind  may  be  impaired  by  grief, 
disease,  melancholy,  old  age,  strange  beliefs,  vice,  or  intemperance :  yet, 
if  he  has  sufficient  ability  to  weigh  and  consider  the  act  of  making  the 
will  and  its  surrounding  circumstances,  it  ^ill  be  valid."  {Am.  d-^Emj. 
Encijdoimdia,  vol.  xi.,  p.  152  and  note.) 

It  is  to  be  observed  that  the  law  regards  with  great  tenderness  the  right 
of  a  person  to  make  a  will ;  one  of  the  strongest  considerations  is  that  he 
is  the  owner  of  the  property  and  has  the  natural  right  to  dispose  of  it  as 
he  sees  fit.  Again,  as  was  said  by  Chancellor  Kent,  ''  The  control  which 
the  law  gives  to  a  man  over  the  disposal  of  his  property  is  one  of  the  most 
efficient  means  which  he  has  in  protracted  life  to  command  the  attention 
due  to  his  infirmities."     ( Van  Alst  vs.  Hunter,  5  Johns  Ch.,  X.  Y..  160.) 

The  law  also  requires  less  mental  capacity  to  make  a  will  than  for 
making  a  contract.  It  is  presumed  that  most  persons  have  meditated 
upon  the  subject  of  the  disposition  of  their  property,  and  are  better  pre- 
pared when  making  their  wills  to  declare  their  intentions  than  to  compre- 
hend new  business.  The  capacity  required  has  reference  to  the  business 
in  hand,  so  that  the  same  degree  of  capacity  to  dispose  by  will  of  a  small 
and  simple  property  is  not  required  as  in  case  of  a  large  and  complicated 
estate  and  many  objects  of  bountv.  {Sheldon  vs.  Dow,  1  Deni.,  X.  Y., 
503.) 

INSANITY  AS  AFFECTING  CONTRACT   OF  MARRLVGE. 

The  same  rule  that  would  apply  to  contracts  in  cases  of  insanity  will 
apply  to  marriage,  so  that  a  party  so  insane  as  to  be  incapable  of  making 


172  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

a  valid  contract  concerning  property  cannot  make  a  valid  contract  of 
marriage.  It  should  be  j^roved,  to  make  sneli  a  contract  invalid,  that  the 
party  had  not  a  rational  idea  of  the  marriage  contract  and  the  relations 
and  duties  incident  to  married  life.  '•  Mere  weakness  of  understanding 
"will  not  invalidate  a  marriage,  nor  ^^^ll  insanity  that  does  not  affect  the 
su}3ject-matter  of  the  contract." 

Where  it  clearly  appears  that  a  person  has  married  an  insane  j)erson 
in  ignorance  of  the  fact,  the  contract  "will  be  declared  void,  for  the  con- 
tract if  void  as  to  one  party  is  as  to  both  {Am.  d-  Eng.  JEncydojxedia,  vol. 
xi.,  p.  140,  notes  1,  2,  3) ;  and  any  party  interested  may  institute  pro- 
ceedings to  jjrocure  a  decree  of  nullity. 

There  is  a  sharp  conflict  of  authorities  in  the  various  States  "whether 
the  marriage  of  an  insane  person  is  void  ah  initio,  so  that  it  may  be  im- 
peached collaterally.  In  Wightman  vs.  Wiglitman,  Chancellor  Kent  held 
that  such  a  marriage  "was  absolutely  void  and  no  decree  of  nullity  "was 
necessary  to  set  it  aside. 

The  cases  that  arise  under  this  branch  of  medical  jm'isprudence  re- 
quire gi'eat  care  and  cii'cumspection  on  the  part  of  the  medical  exj)ert. 
A  majority  of  the  cases  arise  from  imbecility  and  epilepsj',  and  the  great 
question  relates  to  the  degree  of  incapacity.  {Adl  d'  Eng.  EncyclopcBcJia, 
vol.  xi.,  p.  141,  note  1.)  The  history  of  the  party  up  to  the  time  of  the 
marriage,  the  surrounding  cii'cumstances,  are  material  considerations. 

A  judge  of  the  Supreme  Court  of  Massachusetts  trpng  such  a  case 
made  the  remark  '•'  that  the  fact  of  a  party's  being  able  to  go  thi'ough 
the  marriage  ceremouA'-  with  proj^riety  was  prima  facie  e\ddence  of  suffi- 
cient capacity  to  make  the  contract."  It  ^^'^  be  at  once  recognized  by 
the  exjDert  that  such  a  rule  is  not  of  universal  ap2)lication.  It  is  not  a 
sufficient  test  of  caj)acity  that  either  a  man  or  woman  who  has  been  well 
l:)rought  up  Ijehaved  in  comj)any  weU  for  a  short  time,  as  such  behavior 
may  have  become  more  or  less  automatic  from  habit.  A  careful  per- 
sonal examination,  if  practicable,  should  be  had,  and  the  character,  dis- 
position, strength  of  will,  should  aU  be  taken  into  consideration. 

In  cases  of  weak-minded  persons  cpiestions  of  force  or  undue  influence 
upon  the  wiU  may  also  become  important.  Of  com-se  it  is  well  known 
that  any  insanity  or  imbecility  that  has  occurred  since  the  marriage 
furnishes  no  ground  for  a  divorce.  It  was  held  by  the  Supreme  Court 
of  Vermont  that  insanity  was  a  good  defense  to  a  libel  or  suit  for  divorce 
based  upon  a  charge  of  adultery,  the  theory  being  that  there  is  an  ab- 
sence of  a  consenting  will ;  tliis  doctrine  has  been  disputed  in  some  States, 
notal:)ly  Pennsylvania ;  but  tlie  weight  of  authority  is  that  insanity  fur- 
nishes a  valid  defense  in  such  cases.  (See  Bradstreet  vs.  Bradsfreef,  7  Mass. 
471 ;  Matchin  vs.  Matchin,  6  Penn.  332.) 

A  lunatic  is  liable  civdly  to  make  a  compensation  in  damages  to  per- 
sons injured  by  his  acts.  Thus,  for  assaults,  slander,  or  libel,  an  action 
can  be  maintained ;  but  the  fact  of  insanity  can  be  shown  in  mitigation 
of  damages  in  the  two  latter  classes  of  cases  on  the  ground  that  the  words 
spoken  or  ■^^^•itten  could  not  have  an  injurious  effect  of  much  conse- 
quence, varsing  according  to  the  degree  of  insanity  and  the  notoriety  of 
the  lunatic's  condition.  In  such  cases  it  is  for  the  jury  to  determine  ac- 
cording to  the  effect  of  the  acts  of  the  lunatic  what  is  a  fair  measure  of 
damages.  {Am.  &  Eng.  Encyclopcedia,  vol.  xi.,  p.  144,  note,  and  cases 
there  cited.) 


MENTAL  RESPONSIBILITY  OF  THE  INSANE  IN  CIVIL  CASES.      173 

A  question  often  arises  as  to  tlie  competency  of  an  insane  x>ei\son  to 
testify  in  coiu't.  It  is  a  matter  for  the  com-t  to  determine.  The  rule  Ijy 
which  the  court  is  guided  is  as  follows :  "  In  order  to  be  competent  the 
person  must  he  j^ossessed  of  such  an  understanding  as  enables  him  to 
retain  in  memory  the  events  of  which  he  has  been  a  witness,  and  gives 
him  a  knowledge  of  right  and  wrong  sufficient  to  appreciate  the  sanctity 
and  binding  force  of  an  oath,  {Am.  d;  Enrj.  E}i(:ydopmdia,  vol.  xi.,  p. 
145,  note,  and  eases  cited.) 

INSANITY  AS  AFFECTING  CONTRACTS. 

As  a  general  rule  it  requires  a  higher  degree  of  capacity  to  make  a 
contract  than  a  will,  depending  somewhat  upon  the  nature  of  the  trans- 
action, i.e.,  the  complexity  of  the  subject-matter.  The  most  coinmon 
cases  relate  to  deeds,  commercial  paper,  and  partnership.  The  deed  of 
an  insane  person  is  either  void  or  voidable.  It  is  void  when  given  by 
an  insane  person  for  whom  a  committee  has  been  aj^pointed  in  whom 
his  estate  is  vested.  In  all  other  cases  it  is  voidable.  In  order  to  inval- 
idate a  deed  of  an  insane  jjerson  the  suit  must  be  instituted  by  the  grant- 
or after  he  is  restored  to  reason,  or  by  his  committee  or  guardian,  or  by 
his  executor,  administrator,  or  heirs.  {Am.  d:  Enrj.  Eucijchjjaclia,  vol. 
xi.,  p.  149.)  These  rules  apply  to  all  persons  non  compos  mentis  or  labor' 
ing  under  delusions.  All  the  authorities  upon  this  subject,  and  uj)on 
ratification  and  executing  contracts  for  the  sale  of  land,  are  to  be  found 
in  the  same  volume  lief  ore  mentioned,  at  pages  150  and  151. 

It  may  be  stated  that  the  insanity  of  a  maker  or  indorser  of  a  prom- 
issory note  may  be  set  up  as  a  defense  to  an  action  u2)ou  the  note  by 
the  payee  or  any  persons  having  notice  of  such  disability,  or  of  such 
facts  as  would  put  a  reasonable  man  upon  inquuy  as  to  the  competency 
of  the  maker  or  indorser.  But  where  the  insane  party  has  received  full 
consideration,  and  the  note  inured  to  his  benefit,  and  it  has  passed  into 
the  hands  of  a  hona-fide  purchaser  without  notice,  insanity  is  not  a  de- 
fense to  the  note.  It  has  been  held,  however,  that  an  accommodation  in- 
dorser of  a  promissory  note  who  receives  no  benefit  therefrom,  either  to 
himself  or  his  estate,  may  defend  on  the  ground  that  he  was  non  compos 
mentis  at  the  time  of  the  indorsement,  and  this  though  the  holder  had  at 
the  time  of  the  transfer  to  him  no  knowledge  of  the  indorser's  insanity. 
{Am.  &  Eng.  EneyclopcuJia,  vol.  xi.,  p.  144.) 


INSANITY  AND   CEIME. 

BY 

B.  SACHS,  M.D. 


A  FEW  years  ag"o  the  writer  of  this  article  was  discussing  with  one 
of  the  learned  judges  of  the  Superior  Court  of  New  York  the  question 
of  the  responsibility  of  the  insane.  The  writer  stated  his  opinion  that 
up  to  the  present  time  the  legal  tests  of  insanity,  as  accepted  in  many 
of  our  States  and  in  England,  were  entirely  unsatisfactory.  The  judge 
dissented  from  this  view  and  thought  the  matter  a  very  simple  one. 
"  All  we  have  to  do/'  said  he,  "  is  to  determine  whether  the  accused  at 
the  time  he  committed  the  crime  was  able  to  distinguish  between  right 
and  wrong,  and  if  he  knew  that  what  he  had  committed  was  wrong  he 
was  as  responsible  for  that  crime  as  any  sane  person  would  be.-' 

Very  few  legal  minds  have  been  able  to  get  beyond  this  antiquated 
view  of  the  relation  of  insanity  to  crime.  In  Germany  and  France  the 
more  enhghtened  judges  have  been  guided  by  the  opinion  of  medical 
experts,  but  even  there  they  are  not  in  anywise  bound  by  such  an  opin- 
ion, and  it  has  happened  again  and  again  that  the  judge,  having  asked 
for  and  received  the  opinion  of  medical  experts,  has  promptly  set  it  aside 
and  decided  the  cpiestion  to  the  contrary. 

In  England  and  in  this  coimtry,  unfortunately,  the  cpiestion  of  insan- 
ity, and  of  mental  resjionsibility  for  crimes  committed,  is  referred  to 
a  lay  jury.  Judges  and  laymen  acqinesce  in  the  behef  that  a  l.^ody  of 
twelve,  often  ignorant  men,  can  decide  the  question  of  mental  responsi- 
bility, which  under  favorable  circumstances  may  baffle  the  ingenuity 
of  the  most  conscientious  medical  expert.  England  and  America  have 
been  under  the  intluence  of  the  decision  which  the  English  judges  gave 
in  answer  to  certain  questions  which  were  propounded  to  them  hj  the 
House  of  Lords  in  1843,  after  the  atrocious  nnirder  of  Mr.  Drummond 
by  McNaughton.  Maudsley,  whom  I  follow  in  this  matter,  summa- 
rizes the  answer  as  follows:  "To  establish  a  defense  on  the  grounds 
of  insanity  it  must  be  clearly  proved  that  at  the  time  of  committing 
the  act  the  party  accused  was  laboring  under  such  a  defect  of  reason 
from  disease  of  the  mind  as  not  to  know  the  nature  and  quality  of 
the  act  he  was  doing,  or,  if  he  did  know  it,  that  he  did  not  know  he 
was  doing  what  was  A^•l•ong."  It  vn.\l  be  seen  from  this  quotation  that 
the  accused  person  was  not  expected  to  be  able  to  distinguish  between 
right  and  wrong  in  general,  but  that  he  was  at  least  to  know  whether 
the  special  act  M-hich  he  committed  was  right  or  wrong,  or  that  he  Avas 
to  be  entirely  ignorant  of  the  nature  of  the  crime  committed.  This 
"right"  or  "wrong''  test  has  been  the  stumbling-block  in  the  advance  of 

175 


176  -4   SYSTEM  OF  LEGAL  MEDICINE. 

legal  psycliiatiy,  and,  as  a  matter  of  fact,  if  tlie  test  liere  mentioned 
were  to  be  applied  to  the  insane,  nine  out  of  every  ten  Innatics  would 
have  to  be  declared  sane,  for  most  of  them  are  perfectly  awai-e  of  the 
nature  of  the  acts  they  commit.  The  majority  of  them  know  that  they 
are  right  or  T^^'ong  according  to  the  ordinary  standards,  but  they  are 
impelled  either  hj  sudden  influences  or  b^'  sudden  forcible  delusions  to 
the  commission  of  acts  which  they  know  to  be  A^Tong,  and  which,  if  sane, 
they  would  never  have  committed. 

We  shall  have  occasion  to  refer  to  this  question  in  detail ;  for  the 
present  it  suffices  to  point  out  the  difficulties  met  with  in  determining  the 
relation  of  insanity  to  crime.  These  difficulties  have  been  increased  by 
various  unfortunate  cn'cumstanees :  first  of  all,  the  plea  of  insanity  has 
been  frequently  used  in  cases  in  which  there  was  not  the  least  excuse 
for  advancing  it,  and  it  w^as  put  forth  simpl}^  in  the  hope  of  deluding  the 
lay  juiy.  The  plea,  therefore,  has  fallen  into  discredit,  and  the  sus- 
picion is  entertained  in  almost  every  case  in  which  the  plea  is  advanced, 
that  it  is  simply  a  lawj^er's  trick  and  nothing  more.  Yet  if  one  were 
to  take  the  entire  criminal  history  of  this  country  into  account,  I  feel 
satisfied  that  many  more  insane  have  been  j)unished  for  crimes  for 
which  they  were  not  responsible  than  sane  persons  have  escaped  the 
just  penalty  of  theii'  crimes  on  the  plea  of  insanity. 

In  this  connection  it  is  interesting  to  note  how  much  more  frequent 
insanity  is  in  the  criminal  classes  than  in  the  normal  population.  Allow- 
ing for  the  number  of  cases  brought  on  by  imprisonment,  the  statistics 
still  point  to  the  close  relationship)  between  insanity  and  crime.  Accord- 
ing to  Thomson,  twelve  percent,  of  prisoners  in  Scotland  were  insane. 
Of  5432  prisoners,  673  were  insane ;  of  these  57  were  imbeciles  and  57 
were  epileptics ;  but  of  the  total  number  only  53  were  declared  insane  at 
the  time  they  were  sentenced.  In  England  and  Wales  there  is  one  luna- 
tic to  every  432  free  inhabitants ;  but  among  664  accused  of  murder  from 
1857  to  1867,  108  were  insane.     (See  Baer,  Der  Verhrecher,  1893,  p.  258.) 

In  this  country  Dr.  Robinson,  physician  to  the  Eastern  State  Peniten- 
tiary in  Pennsylvania,  states  that  in  five  years  he  has  had  to  deal  with 
about  3500  convicts  for  periods  of  one  year  to  five  years ;  of  these  245 
were  insane  upon  reception,  40  had  insanity  de^^elop  during  theii'  incar- 
ceration, and  20  were  guilty  of  simulating  insanity. 

In  a  paper  read  in  Washington  in  1892,  Dr.  Allison  tabulates  the 
crimes  committed  by  87  court  cases  now  in  the  New  York  State  Asylum 
for  Insane  Cruninals. 

Murder 38 

Assaults  in  the  fii'st  degi'ee  and  attempts  to  kill 18 

Dangerous  assaults 10 

Arson  and  attempt  at  arson  8 

Burglary  and  larceny 10 

Bigamy 1 

Horse-stealing 1 

Disorderly 1 

Total 87 

Another  difficulty  that  besets  the  question  is  one  that  should  be  seri- 
ously considered.  The  layman  argues  that  it  is  all  very  well  for  medical 
men  and  for  sentimentalists  to  excuse  crime  on  the  plea  of  insanity,  but 


JNSANirr  AM)   CRIME.  177 

wliat  is  society  to  do  in  order  to  protect  itself  apfainst  the  crimes  of  tlie 
insane  f  As  medical  men  we  are  l)ound  to  defend  tlie  i-i<^hts  of  the  in- 
sane, but  as  mendjers  of  society  we  must  a(!knovvl(Mlo-e  that  the  latter  has 
full  rig'hts,  and  that  it  should  enjoy  imnninity  from  crimes  due  to  dis- 
eased nunds.  A  remedy  must  be  soug-ht  for  the  protection  of  society, 
and  this  remedy  is  not  only  the  establishment  of  asylums  for  the  ci-imiual 
insane,  l)ut  also  the  retention  of  lunatics  who  have  committed  crimes  in 
such  asylums  for  years,  if  not  for  the  remainder  of  their  lives,  or  at  least 
until  the  daiig'er  of  their  committing  simihir  crimes  has  passed.  In  a 
recent  trial  in  this  city  the  experts  did  well  who  urg'cd  that  a  woman 
who  was  declared  innocent  of  the  crime  of  murdering  her  children  should 
not  be  allowed  to  go  scot-free,  but  that  she  should  l)e  sent  to  an  asylum 
and  her  mental  condition  carefully  watched.  Society  must  iind  some 
means  of  protecting  itself,  but  it  should  not  be  guilty  of  judicial  murder. 
The  national  conscience  is  no  longer  responsible  for  the  execution  of 
witches,  for  the  torture  of  those  who  were  supposed  to  be  possessed  of 
the  devil,  but  it  has  until  recent  years  been  responsible  for  the  death  of 
assassins  whose  deeds,  as  in  the  case  of  Guiteau,  for  instance,  Avere  clearly 
the  result  of  mental  aberration.  Let  society  proceed  with  all  due  rigor 
against  those  who  are  the  instigators  of  crime ;  let  it  adopt  the  most 
strenuous  measures  against  anarchists  and  other  enemies  of  societ}'  whose 
revolutionary  doctrines  generally  supply  the  torch  that  was  needed  to 
excite  weakened  and  diseased  minds  to  the  commission  of  outrageous 
crimes;  but  let  the  poor  unfortunate  lunatic  or  iml)ecilewho  has  yielded 
to  anarchistic  preachings  or  to  the  impulses  of  his  morbid  mind  not  suffer 
the  x)enalty  of  a  crime  for  which  he  is  iu)t  responsible. 

The  (piestion  arises.  When  shall  the  plea  of  insanity  be  considered 
valid  in  extenuation  of  crime "?  The  only  proper  answer  to  this  question, 
in  the  light  of  the  present  condition  of  psychiatry,  is  that  no  xjerson  filiall 
he  considered  guilty  of  a  crime  if,  at  the  time  the  crime  ivas  committed, 
he  was  snferiuf/  from  any  form  of  mental  disease.  The  medical  expert 
should  be  called  upon  to  state  whether  the  person  accused  is  or  Avas  sane 
or  insane,  and  if  insane  he  should  not  be  held  resiionsil;)le  for  his  acts. 
In  several  recent  trials  in  this  country  the  question  has  been  put  in  this 
broad  wa}^,  and  the  answei-s  of  the  exi)erts  have  l)een  accepted  Avithout 
any  reference  to  the  older  legal  tests  of  responsil)ilit3'.  Let  the  medical 
man's  duties  also  end  with  the  determination  of  this  purely  medical  ques- 
tion, and  let  the  law  and  its  exponents  accept  the  responsibility  for 
everything  else.  But  in  order  that  the  question  of  sanity  or  insanity 
shall  be  justly  decided,  it  is  necessary  that  the  opinion  shall  be  expressed 
by  those  avIio  are  truly  (pialified  to  give  an  opinion. 

Psychiatry  is  a  veiy  special  bi-anch  of  medicine.  It  does  not  con- 
stitute part  of  the  regular  medical  training  in  this  country  or  in 
Europe;  yet  in  some  of  the  most  important  trials  of  recent  years  any 
medical  man  has  been  accepted  as  expert,  and  his  opinions  Iuxa'C  been 
held  to  be  fully  as  valuable  as  those  of  a  man  Avho  has  deA'oted  years  to 
the  study  and  practice  of  this  special  branch.  There  is  no  more  reason 
to  accept  the  opinions  of  a  gynecologist  in  questions  of  insanity  than 
there  Avould  be  in  accepting  the  opinions  of  an  alienist  on  the  feasibilit.y 
of  an  operation  upon  the  eye  or  the  removal  of  an  abdominal  tumor. 
But  if  the  expert  has  been  ])ro])erly  chosen  another  refm-m  in  the  nu^th- 
ods  of  medico-legal  procedure  is  urgently  called  for :  the  expert  should 


178  -4   SYSTEM  OF  LEGAL  MEDICINE. 

not  be  made  a  partisan  to  one  side  or  the  other,  but  the  facts  should  be 
submitted  to  him  as  imjDartiall}^  as  possible,  and  he  should  determine 
the  question  of  sanity  or  insanity  after  considering  such  facts,  and,  if 
possible,  after  an  unprejudiced  examination  of  the  supposed  criminal* 

In  spite  of  all  the  defects  of  com*t  procedure  in  the  United  States  in 
matters  affecting  insanity,  it  is  a  satisfaction  to  know  that  the  riUings  of 
the  more  enlightened  judges  in  this  country  indicate  a  decided  advance 
upon  the  princij)les  laid  down  by  the  English  coiu'ts.  In  the  State  of 
New  York  the  statutes  simply  state  that  "No  act  done  by  a  person  in  a 
state  of  insanity  can  be  punished  as  an  offense."  The  humane  spirit  of 
this  statute  cannot  be  denied,  and  it  will  be  noted  that  nothing  is  said 
in  it  of  the  responsibility  of  the  criminal  in  case  he  was  able  to  decide 
between  the  right  and  the  Avrong  of  the  act  he  committed,  whether  he 
knew  or  did  not  know  that  it  was  contrary  to  the  law  of  the  land,  or 
whether  the  act  was  the  natural  outcome  of  his  insane  impulses  or  his 
insane  delusions.  The  fact  to  be  determined  is  simply  whether  the  per- 
son accused  is  sane  or  insane,  and  if  insane,  whatever  the  form  of  insan- 
ity may  be,  he  is  not  resjDonsible  for  the  deed  committed.  The  spirit  of 
this  statute  throws  greater  res]3onsibihty  upon  the  medical  expert.  The 
principle  of  the  statute  of  the  State  of  New  York  is  not  yet  adopted 
by  all  other  States  of  the  Union,  and  is  very  far  from  being  adopted  in 
England.  We  must  therefore  still  discuss,  though  we  may  do  it  more 
briefly,  the  older  tests  of  responsibility,  and  determine  to  what  extent  a 
person  may  be  liable  for  acts  he  has  committed.! 

In  Germany  the  law  revolves  upon  the  j)oint  that  the  sane  individual 
has  free  will,  and  if  by  reason  of  disease  the  free  exercise  of  the  will  is 
precluded  the  person  cannot  be  held  responsible  for  the  acts  committed. 
The  New  York  statute  is  evidently  superior  to  this,  for  to  decide  simply 
upon  the  free  determination  of  the  wiU  involves  a  great  many  diificul- 
ties,  above  all  that  of  proving  to  judge  and  jury  that  the  person  in  ques- 
tion could  not  exercise  his  own  free  will,  and  that  such  exercise  was  in 
any  way  influenced  by  the  delusions  or  other  symptoms  exhibited  by 
the  accused.  It  leaves  out  of  consideration  altogether  the  question  of 
violent  acts  due  to  sudden  morbid  impulses,  and  it  requires  the  applica- 
tion of  sane  reasoning  with  regard  to  insane  delusions  and  impulses. 

The  English  courts  seem  to  be  bound  more  than  all  others  by  ancient 
precedent,  and  in  spite  of  vigorous  protests  by  eminent  English  jurists 
and  many  eminent  medical  men  the  old  order  of  things  still  obtains.  It 
is  fair  to  say  that  more  judicial  murders  are  committed  in  enlightened 

*  For  a  fuller  discussion  of  the  evils  attending  the  methods  of  eliciting  medical- 
expert  testimony  the  reader  is  referred  to  a  short  article  by  the  present  writer  in  the 
Medical  Examiner  for  July,  1892. 

t  The  "  right  and  the  wrong  "  in  law,  the  tolerant  and  the  intolerant  spirit,  are 
well  illustrated  by  two  judges'  charges.  In  the  case  of  Stevens  vs.  State  (see  Lawson, 
pp.  88  et  seq.).  "  If  the  jury  believe  from  the  evidence  that  the  defendant  knew  the 
difference  between  right  and  wrong  in  respect  to  the  act  in  question  [murder]  ;  if  he 
was  conscious  that  such  act  was  one  which  he  ought  not  to  do ;  and  if  that  act,  at  the 
same  time,  was  contrary  to  the  law  of  the  State,  then  he  is  responsible  for  his  act." 
Contrast  with  this  nai-row  view  the  charge  of  Chief-Justice  Perley,  who  instructed 
the  jury  "  that  the  verdict  should  be  not  guilty  by  reason  of  insanity,  if  the  killing  was 
the  offspring  or  product  nf  mental  disease  in  the  defendant;  that  neither  delusion  nor 
knowledge  of  right  and  wrong,  nor  design  or  cunning  in  planning  and  executing  the 
killing  and  escaping  is,  as  a  matter  of  law,  a  test  of  mental  disease,  but  is  purely  a 
matter  of  fact  to  be  determined  by  the  jury." 


IXSJXITY  AXD    CRIME.  I79 

England  tliaii  iu  any  other  country  of  the  ci\'ilizo(l  world*  English  judj;es 
iind  those  who  are  inclined  to  follow  them  in  this  country — and  many 
do — still  fall  back  upon  the  simple  test  of  whether  the  accused  at  the 
time  of  committing-  the  act  was  able  to  distinguish  between  the  rig:ht  and 
Avrong'  of  it,  and  if  he  was  so  al>le  to  distinguish  he  is  as  res])onsible  for 
the  act  as  though  he  were  entirely  saiu'.  There  are  relatively  few  luna- 
tics who  commit  violent  acts  who  are  not  aware  at  the  time  tlicy  commit 
the  act  that  it  is  wrong,  but  their  judgment  is  befogged  for  the  time 
being,  the  motives  which  impel  them  are  different  from  those  which 
guide  the  sane,  their  passions  are  more  uncontrollable,  and  they  often 
act  in  obedience  to  delusions  which  impel  them  to  commit  deeds  which 
they  know  to  be  wrong,  and  which  nuiy  be  as  abhorrent  to  them  as  they 
are  to  others.  Many  an  insane  individual  has  repented  an  atrocious 
crime  the  very  next  moment  after  he  had  committed  it.  It  was  clear  to  the 
English  judges  that  the  "right''  or  "A\Tong"  test  could  not  be  upheld  in 
every  instance,  and  for  that  reason  further  rulings  were  necessarily  made 
with  reference  to  the  influence  of  insane  delusions,  insane  motives  and 
impulses ;  and  iu  making  such  rulings  they  have  revealed  a  deplorable 
ignorance  of  the  peculiar  changes  which  the  mind  undergoes  in  disease. 
Thus  the  judges  declare,  in  answer  to  the  question  whether  a  person  who, 
under  an  insane  delusion  as  to  existing  facts,  commits  an  offense  iu  con- 
sequence thereof,  should  thereby  be  excused,  that  such  a  person  must 
be  considered  as  responsible  as  if  the  facts  of  the  delusion  were  real ;  and 
they  state  furthermore  that  if  a  person  under  the  influence  of  a  delusion 
supposed  another  man  to  be  in  the  act  of  attempting  to  take  his  life,  and 
killed  that  man  in  self-defense,  such  person  would  be  exempt  from  punish- 
ment. But  if  he  was  suffering  from  a  delusion  that  another  had  inflicted 
serious  injury  to  his  character  and  fortune,  and  he  killed  him  in  revenge 
for  such  supposed  injury,  he  would  be  liable  to  punishment.  Nothing 
more  absurd  than  this  has  &yev  been  "s^i-itten  by  a  sane  mind. 

A  person  who  has  an  insane  delusion  is  expected  to  be  able  to  reason 
regartling  the  facts  of  the  delusion  as  every  sane  person  would ;  he  is 
expected  to  be  guided  liy  sane  motives  and  to  have  none  but  sane  im- 
pulses with  reference  to  his  delusion.  As  Maudsley  puts  it,  "  He  is  ex- 
pected to  be  reasonable  in  his  uni-eason,  sane  iu  his  insanity."  This 
doctrine  is  the  outcome  of  the  older  theories  of  partial  insanities,  im- 
plying that  a  person  could  be  sane  in  all  other  respects  while  absolutely 
and  hopelessly  insane  on  some  one  single  point  of  lielief.  Modern  psy- 
chiatry has  taught  us  that  this  older  doctrine  is  wholly  untenable,  and 
that  the  mere  continued  existence  of  a  single  delusion,  whatever  its  char- 
acter may  be,  proves  that  the  entire  mind  is  diseased — that  the  logical 
faculties,  the  judgment,  and  the  reason  of  the  person  have  lieen  seriously 
impaired.  If  we  consider,  furthermore,  that  any  person  atflicted  with  a 
single  delusion  is  complete^  dominated  by  it,  the  injustice  of  insisting 
that  he  shall  be  guided  by  ordinary  reasoning  will  be  evident  at  once. 
The  theory  of  monomanias  has  done  much  mischief  in  psychiatry,  but  it 
has  done  infinitely  more  in  nu^dical  jurisprudence. 

The  English  law  insisted  that  the  criminal  was  responsible  for  his 
act  if  he  knew  that  such  act  was  contrary  to  the  law  of  the  land.     Tliis 

*  According  to  tlie  Lancet,  influential  sub-committees  of  the  Br.  Medical  and  of 
the  MtHlico-Psychologieal  Associations  have  been  appointed  to  investigate  and  report 
upon  this  subject. 


180  ^   SYSTEM  OF  LEGAL  MEDICINE. 

was  a  departure  from  tlie  strict  "right"  or  "wrong"  test,  for  iu  many  an 
instance  the  insane  are  thoroughly  cognizant  of  the  law  of  the  land  and 
vet  hold  a  very  diifereut  opinion  as  to  right  and  wrong  in  obedience  to 
their  own  delusions.  We  need  not  enter  into  further  argument  regard- 
ing this  older  test.  It  is  conceded  on  all  sides  that  the  insane  may  have 
a  perfect  knowledge  of  right  and  wrong  at  the  time  a  criminal  act  is 
committed  and  yet  not  be  responsible  for  the  act.  The  influence  of  de- 
lusions is  also  liberally  conceded,  but  much  more  difficulty  is  encountered 
in  the  attempt  to  represent  to  judge  and  jury  that  the  motives  of  the 
insane  are  very  different  from  those  of  persons  with  healthy  minds,  and 
that  sudden  morbid  impulses  are  responsible  for  many  acts  of  violence. 

Let  us  take  up  the  matter  of  the  motives  of  the  insane  as  a  guide  to- 
action.  Persons  in  good  mental  health  are  expected  to  be  guided  by  the 
exercise  of  their  own  judgments,  by  their*  own  and  the  accumulated  ex- 
perience of  others,  before  proceeding  to  any  rash  act;  and  in  addition  tO' 
this  the  fear  of  punishment  is  supposed  to  exercise  a  very  powerful,  de- 
terring influence.  A  sane  person  is  excused  for  an  act  of  violence  only 
on  the  ground  of  self'-defense,  and  self-defense  only  in  case  he  is  satis- 
fied that  his  life  is  being  actually  attempted.  Feelings  of  revenge  are 
not  allowed  as  an  excuse  for  criminal  acts,  and,  above  all,  the  sane  per- 
son iu  every  civilized  community  is  not  allowed  to  take  the  law  into  his 
own  hands.  The  diseased  mind  loses  sight,  however,  of  all  these  restrain- 
ing influences  ;  the  judgment  of  the  insane  individual  becomes  defective,, 
and  his  reasoning  is  warped  by  the  presence  of  delusions  and  by  the 
change  iu  his  temperament.  There  is  httle  difficulty,  as  a  rule,  in  excus- 
ing crime  that  is  the  direct  result  of  a  delusion.  Any  jury  will  exempt 
the  accused  person  from  punishment  if  his  acts  followed  as  naturally 
upon  the  delusion  as  they  would  in  sane  persons  if  the  facts  of  the  delu- 
sion were  real.  But  trouble  is  certain  to  arise  whenever  the  motives  lead- 
ing to  an  insane  act  are  unknown  or  do  not  appear  to  be  the  direct  result 
of  a  delusion.  There  is  the  famous  story  of  the  boy  who  was  extremely 
fond  of  windmills.  He  was  sent  far  away  from  his  home  for  the  improve- 
ment of  his  health ;  while  away  he  induced  a  little  girl  to  go  with  him 
to  the  woods,  and  there  committed  a  brutal  murder.  He  surrendered 
himself  at  once  to  the  proper  authorities,  and  when  asked  why  he  had 
committed  the  crime  his  reason  wa,s  one  which  few  would  have  surniised. 
He  was  anxious  to  see  the  windmills,  and  he  knew  that  after  committing 
an  act  of  this  sort  he  would  be  returned  to  his  own  birthplace,  where  his 
desire  for  whidmills  would  be  fully  gratified.  Could  any  sane  mind  have 
suspected  such  a  motive?  What  an  unbalancing  of  all  mental  facul- 
ties this  implies ! 

Take  the  case  related  by  Dufour :  A  paranoiac  was  anxious  to  flee  to 
America  to  escape  from  supposed  enemies.  Having  no  monej^  he  decided 
to  murder  and  rob  a  rich  old  couple.  He  bought  a  hammer,  blackened 
his  face,  and  l)ought  a  linen  blouse  to  cover  his  clothes  and  keep  them 
from  becoming  blood-stained.  In  this  there  was '  premeditation  and  a 
desire  to  conceal  liis  person,  also  a  knowledge  of  the  wrong  done ;  but 
marked  insanity  withal. 

Among  jurists  and  medical  men  there  has  been  some  hesitation  in 
allowing  for  the  effect  of  siidden  morbid  impulses.  The  plea  of  insanity 
has  in  such  instances  been  taken  to  be  a  mere  subterfuge.  It  is  claimed 
that  even  among  the  sane  sudden  impulses  are  common  enough,  and  that 
if  every  sane  individual  were  to  act  upon  the  numerous  impiilses  starting 


INSANITY  AND   CRIME.  181 

up  witliin  him,  he  too  might  be  guilty  of  criminal  acts.  The  very  sud- 
denness of  the  impulses  in  the  insane,  the  fact  that  the  impulses  cannot 
he  subdued,  that  the  person  nnist  act  upon  it,  constitute  the  strongest 
proof  that  sueli  impulses  are  the  <)ffs})ring  of  a  diseased  mind.  It  is  a 
mistake  to  think,  furthermore,  that  the  insane  yield  to  their  impulses 
without  any  attempt  at  self-restraint.  Were  this  true  we  should  have 
dozens  of  suicides  and  homicides  for  every  one  that  actually  occurs.  I 
have  always  felt  how  true  Meynert's  remark  was  which  he  made  vei-ljally 
to  his  students  on  one  of  his  rounds :  "  Considering  the  delusions,  the 
impulses,  and  the  passions  of  the  insane,  there  is  more  self-restraint  in- 
side an  asylum  than  there  is  outside  of  it."  Every  one  of  us  has  been 
witness  to  the  struggle  which  those  who  are  permanently  or  temporarily 
deranged  have  made  in  order  to  resist  the  sudden  impulses  coming  over 
them.  At  some  time  a  limit  of  endurance  is  reached,  and,  unfortunately, 
the  insane  individual  has  to  yield  to  the  sudd(ni  impidses  urging  him  on 
to  commit  every  possil)le  form  of  crime.  Tlie  laity  and  many  medical 
men  may  claim  that  since  the  person  in  question  and  since  others  have 
been  known  at  various  times  to  resist  morbid  imj)ulses,  it  was  his  duty 
on  this  special  occasion  again  to  resist.  We  may  consider  it  unfortunate 
that  he  was  not  able  to  do  so,  but  can  surely  not  hold  him  resj^onsible 
for  yielding  to  impulses  which  were  so  strong  as  to  control  his  entire 
being.  The  criminal  act  is  the  natural  result  of  his  mental  condition,  the 
natural  outcome  of  mental  disease,  and  that  must  decide  the  lack  of  re- 
sponsibility, while  there  is  room  for  congratulation  that  the  accused  and 
others  so  often  I'csist  the  sudden  biddings  of  an  impidse. 

I  grant  that  there  are  great  difficulties  in  the  way  of  accepting  this 
theory  of  morbid  impulses  as  a  defense  for  criminal  acts.  It  may  be 
urged  that  every  act  is  the  result  of  a  sudden  impulse,  and  that  if  we 
alloAv  the  defense  in  one  instance  we  must  accept  it  in  all.  To  avoid 
this  dilemma  it  is  only  fair  to  expect  that  some  other  signs  of  mental 
derangement  shall  be  discovered  in  a  person  who  has  yielded  to  a  ]norl)id 
impulse,  or  that  proof  shall  be  forthcoming  that  the  person  has  had  pi-e- 
vious  impulses  of  this  kind  to  which  he  has  unfortunately  yielded.  If 
such  evidence  is  not  easy  to  procm*e,  further  observation  of  the  accused 
individual  should  supply  the  necessary  evidence  as  to  his  mental  condi- 
tion. It  may  be  urged,  on  the  other  hand,  that  the  impulse  which  led  to 
the  commission  of  the  crime  was  the  first  and  onhj  impuhe  of  the  sort ; 
that  with  the  exception  of  this  "  temporary  fit  of  insanity,"  as  it  is  j)opu- 
lai'ly  called,  the  person  is  entirely  sane.  I  am  not  willing  to  give  my 
approval  to  such  an  argument,  for,  as  a  matter  of  fact,  single  impulses 
of  this  description  are  very  rare  indeed,  and  if  the  person  is  kept  under 
proper  ol)servation  further  evidence  will  sui-ely  be  found. 

It  is  interesting  to  note  the  relation  which  these  morbid  impulses 
hold  to  conditions  occurring  during  normal  life.  Every  one  has  turned 
out  the  light  in  his  bedroom,  and  has  been  suddenly  seized  by  the  fear 
that  the  light  was  not  properly  turned  out  and  that  the  gas  might  be 
escaping.  He  gets  up,  finds  he  is  mistaken,  goes  to  bed.  and  after  a 
few  niinutes  may  be  stai-tled  again  l>y  the  same  fear.  "Uliat  has  hap- 
pened to  him  is  tliat  a  sudden  morlud  conception  arises  in  his  mind  as 
to  the  escape  of  gas,  and  he  is  not  al)le  to  allay  the  fear  by  the  methods 
which  ordinarily  carry  conviction.  Returning  to  one's  door  again  and 
again  in  order  to  make  sure  that  it  is  properly  locked :  the  fear  that  the 
letter  which  has  just  been  mailed  was  not  properly  sealed ;  or  the  fear 


Ig2  A   SYSTEM  OF  LEGAL   MEDICINE. 

that  one  forgot  to  sign  a  letter  or  a  check — all  sncli  imperative  concep- 
tions are  of  daily  occuiTence  in  the  hte  of  health}-  indi^'id^als,  are  often 
regarded  as  annoying  occurrences,  but  that  is  about  all.  If  we  carry  this 
physiological  oceui-rence  just  one  step  further  the  morbid  conceptions 
may  become  i>ermanently  lodged  in  the  mmd  and  may  lead  to  morbid 
impulses.  Who  has  not  felt  when  standing  on  a  giddy  height  that  he 
would  be  suddenly  drawn  into  the  abyss  below,  and  for  fear  that  he 
might  peld  to  this  feehng  has  stepped  back  a  safe  distance  from  the 
abyss  ? '  Others  on  board  a  vessel  have  felt  suddenly  a  peculiar  sensation, 
as "^ though  they  would  be  inevitably  di-agged  into  the  water;  they  step 
back  unconsciously  in  order  not  to  give  way  to  this  special  impulse.  At 
the  sight  of  a  knife  many  a  person  has  felt  that  he  or  she  might  do 
some  harm  \\ith  such  a  weapon.  A  few  j^ears  ago  an  unhappy  woman 
came  to  my  clinic,  and  stated  that  whenever  she  sat  down  to  table 
with  her  husband  and  her  five-year-old  child,  whom  she  dearly  loved,  she 
felt  as  though  she  would  have  to  seize  the  knife  and  kill  the  child.  She 
stated  that  she  passed  through  the  most  intense  agony,  for  she  would 
not  wilhngly  harm  a  hair  on  the  child's  head.  She  came  to  me  begging 
for  advdce  what  to  do.  I  told  her  that  she  must,  of  course,  control  her- 
seK  under  all  circumstances,  but  that  it  would  Ije  advisable  for  her  to 
separate  for  some  length  of  time  from  her  child,  to  which  she  readily 
consented.  A  few  weeks  later  she  ajtpeared  again,  stating  that  now  that 
her  child  was  away  she  had  exactty  the  same  feelings  with  regard  to  her 
husband,  and  that  unless  she  were  placed  under  restraint  she  would 
some  day  kill  him.  Husband  and  vvif  e  too  had  to  lie  separated,  but  wheth- 
er they  were  ever  reunited,  or  whether  the  poor  woman  has  committed 
some  act  of  violence  in  obedience  to  her  impulses,  I  cannot  say.  Few 
sane  people  would  control  themselves  as  this  woman  did  had  they  similar 
impulses.  AVho  would  blame  such  an  unfortunate  creature  if  at  such 
times  she  had  vielded  to  the  promptings  of  her  diseased  mind  ?  There  is 
a  stoiy,  also,  of  a  nurse  who  was  attending  a  child  of  Alexander  von 
HumbVjldt,  who  begged  to  be  dismissed  from  service  because  every  time 
she  bathed  the  child' and  saw  its  pm-e-white  skin  she  felt  impelled  to  do 
it  some  harm.  How  closely  akin  to  this  state  is  the  entirely  normal  con- 
dition of  people  who,  in  hugging  a  little  child,  feel  as  though  they  could 
bite  a  bit  of  its  cheek  !  We  need  not  refer,  in  addition,  to  the  innumer- 
able variations  of  this  sudden  play  of  the  morbid  impulses,  to  the  sudden 
feelings  or  impulses  arising  in  husband  or  wife  as  a  result  of  conceptions 
suggesting  the  need  of  the  immediate  death  of  the  life-partner.  The 
important  point  to  be  remembered  is  that  morbid  impulses  constitute  a 
very  grave  series  of  symptoms;  that  they  occm*  in  different  forms  of  in- 
sanity, as  we  shall  see  later ;  and  that  far  from  being  a  mere  subterfuge 
as  a  defense  for  crime  they  are  too  often  the  actual  cause  of  the  worst 
outrages. 

Tlie  ei-iminal  lunatic  does  not  commit  crimes  merely  as  a  result  of 
delusions,  hallucinations,  or  morbid  impulses.  He  may  have  inherited 
insane  tendencies ;  his  nature  may  be  perverse,  degenerate  ;  he  has  been 
reared  in  crime,  and  his  wrong-doing  is  inevitable.  This  is  pai-ticularly 
true  of  those  exliibiting  marked  moral  defects.  In  these  individuals  the 
relation  between  hereditary  mental  disease  and  crime  becomes  a  very 
close  one.  The  Italian  school  of  criminologists,  under  the  able  leader- 
ship of  Lombroso,  has  devoted  much  labor  to  the  elucidation  of  this 


PLATE   II.* 


— «£^7 


Fig.  A. 


Fig.  B. 


Fig.  C. 


Fig.  D. 


CRIMINALS  WHO  HAVE  BECOME   INSAXE  ("DEGENERATE  TYPE"). 

Fig.  A. — Aged  .50  years:  "Frenchy:""  murder  in  the  second  degree:  killed  "Old  Shake- 
•speare' ' ;  asjTiiinetry  of  head  and  face ;  deep  orbital  arch ;  large  ears.  Became  melancholy  and 
emotional. 

Fig.  B. — Aged  29  years:  "instinctive  criminal :*"  several  convictions:  had  sti'ong  delusions 
;ind  hallucinations:  assaulted  fellow-convicts.     Small  head:  large  lower  jaw. 

Fig.  C— Aged  24  years:  murder  in  the  first  degree:  said  to  have  been  .insane  previously; 
claims  homicide  in  self-defense.    Delusions  of  persecution.     Dolichocephalus. 

Fig.  D.— Aged  31  years:  repeated  convictions  for  larceny  and  assault.  Has  auditory  and 
'.isual  hallucinations ;  lower  jaw  massive :  head  small. 


*  [The  illustrations  on  Plates  II.  and  III.  are  of  inmates  of  !Matteawan  State  Hospital  of 
Criminal  Insane,  from  photographs  kindly  furnished  by  Dr.  Allison.  Superintendent,  and  Dr. 
Robert  B.  Lamb.     The  author  is  also  indebted  to  the  courtesy  of  Dr.  Carlos  F.  MacDonald.] 


lyiSjyjTY  AND  ciiiMi':.  183 

question,  ondeavoriiiGf  to  pi-ovo,  by  carefnl  craniometrinal  measnremeiit, 
abuorinalities  of  the  criminal  skull,  of  the  face,  and  of  the  entire  organ- 
ism, that  the  criminal  bears  the  distinct  signs  of  deficient  mental  and 
physical  endowment.  He  is  a  degenerate  individual,  and  if  his  degen- 
eracy is  not  the  equivalent  of  insanity  it  is  at  least  next  of  kin  to  it. 
The  new  school  has  not  adojjted  the  phrenology  of  Gall,  it  has  not  as- 
signed to  various  parts  of  the  skull  the  various  peculiarities,  vices,  and 
virtues  of  the  individual,  l)ut  it  has  endeavored  to  show  that  tlie  skull 
capacity  as  a  whole  is  deficient,  or  that  the  frontal  region,  which  is  gen- 
erally considered  to  be  the  chief  seat  of  intelligence,  is  deficient  in  the 
criminal  classes.  But  this  same  region  is  deficient  in  other  individuals 
who  may  lack  intelligence  but  are  not  in  any  sense  criminal.  It  is  surely 
wrong  to  claim  that  every  criminal  is  insane,  temporarily  or  perma- 
nently, or  to  claim  the  existence  of  insanity  in  a  crindnal,  unless  there 
be  some  further  evidence  of  insanity  in  addition  to  the  crime  committed. 
Lombroso  in  Italy  and  Benedikt  in  Vienna  have  been  the  chief  stu- 
dents of  cephalometric  measurenu^nts.  I  append  one  table  taken  from 
Lombroso's  work,  showing  the  varying  capacity  of  criminal  skulls  and 
those  of  insane  or  epileptic  individuals. 


Skull  Capacity. 

Murderers. 

Thieves. 

Sane. 

Insane. 

Epileptic. 

Cubic  centimeters. 

(o) 

(O 

Qi) 

(%) 

(%) 

1101-1150 

0 

2.9 

0 

0 

0.5 

1151-1200 

0 

11.7 

0.9 

1 

0 

1201-1250 

0 

0 

1.7 

3 

0 

1251-1300 

11.3 

2.9 

4.3 

3 

2.0 

1301-1350 

9.4 

11.7 

6.9 

10 

1.0 

1351-1400 

16.9 

11.7 

12.9 

8 

7.2 

1401-1450 

11.3 

11.7 

12.9 

22 

8.8 

1451-1500 

15.0 

17.6 

15.5 

12 

14.4 

1501-1550 

5.4 

17.6 

14.6 

12 

20.1 

1551-1600 

11.3 

8.6 

1-1.2 

11 

16.1 

1601-1650 

13.2 

0 

9.5 

10 

11.3 

1651-1700 

5.4 

2.9 

5.2 

2 

11.9 

1701-1750 

0 

0 

3.4 

4 

3.62 

1751-lSOO 

0 

0 

0.9 

1 

1.52 

1801-2000 

0 

0 

0 

1 

2.59 

Lombroso  draws  the  conclusion  that  the  skull  capacity  of  criminals 
is  less  than  that  of  normal  individuals,  and  that  this  diminution  is  much 
more  marked  among  thieves  than  murderers ;  from  which  we  might 
infer  that  murderers  are  more  highly  organized  individuals  than  thieves. 
In  skull  measurements  the  criminal  (according  to  Lombroso)  is  nearer 
the  insane  than  the  healthy  individual.  But  such  statistics  should  not 
be  overstated ;  the  variations  may  indicate  a  generally  defecti\"e  organ- 
ism, and  in  the  individual  case  variations  from  the  average  cannot  be 
depended  upon  as  evidences  of  an  insane  temperament  in  its  relation  to 
the  crime  committed. 

Benedikt,  who  has  examined  a  large  number  of  Crerman  criminals, 
concludes  that  in  central  Europe  the  army  of  criudnals  is  recruited  fi'om 
the  lower  anthropological  order  of  the  various  races.* 

*  The  present  writer  lias  been  tempted  to  enter  iipou  the  question  of  the  degen- 
eracy of  the  "  instinctive  "  criminal,  but  it  would  have  been  aside  from  the  main  sub- 
ject. WhiU^  there  is  littU'  doiiltt  tliat  the  Italian  school  has  exceeded  the  warrant  of  its 
facts  in  establishing:  various  criminal  types  and  in  attaching  undue  im])ortance  to  signs 
of  degeneracy  in  the  individual,  it  has  established  for  all  times  the  intimate  relations 


184 


A   SYSTEM  OF  LEGAL  MEDICINE. 


"Witliont  reference  to  couflicting  theories  it  will  be  well  to  study  care- 
fully aud  soberly  the  forms  of  insanity  which  are  known  to  lead  fre- 
quently to  the  commission  of  crime. 

SPECIAL   FORMS   OF   INSANITY  IN   THEIR   RELATION   TO   CRBIE  * 

Crime  may  result  from  defective  development  as  well  as  from  disease 
of  the  mind.  From  a  practical  standpoint  it  matters  httle  whether  the 
symptoms  exhibited  in  a  given  case,  or  the  actions  committed,  are  due 
to  improper  gi'owth  of  brain  (and  mind)  or  to  actual  disease  of  a  brain 
that  was  once  normal.  Both  forms  are  morbid  in  the  sense  that  they 
indicate  a  departui'e  from  the  normal.  But  as  the  brain  and  the  men- 
tal faculties  are  not  fully  developed 
until  the  age  of  puberty  has  been 
long  passed,  we  must  also  include 
the  consideration  of  those  crimes 
which  are  the  result  of  unripe  judg- 
ment rather  than  of  disease  ;  but  as 
a  matter  of  fact  very  few  youthful 
persons  are  guilty  of  violent  or 
wrong  acts  unless  they  bear  the 
germs  of  impending  insanity  or  the 
traces  of  a  tainted  family  record. 

Persons  cannot  be  held  respon- 
sible for  criminal  acts — 

1.  If  they  have  not  yet  attained 
the  age  at  which  they  can  be  expected 
to  realize  the  full  import  of  their  ac- 
tions, although  they  may  appear  to 
be  capable  of  such  development  later 
on. 

2.  If  they  give  evidence  of  ar- 
rested or  defective  development  of 
the  brain  (idiocy  and  imbecility). 

3.  If  they  exhibit  evidence  of  such  disease  of  the  mind  as  affects 
the  fully  developed  brain,  or  of  conditions  of  degeneration  that  become 
apparent  only  after  body  and  mind  have  matured. 

4.  If  at  the  time  of  the  commission  of  crime  they  were  in  an  uncon- 
scious condition  or  in  a  state  of  altered  consciousness. 


I'/ '      ^ 


^     V      -J 


Fig.  25. — Ravachol:  asymmetry  of  face, 
deviation  of  nose,  slight  growth  of  beard, 
and  firmly  set  jaws. 


THE   RESPONSIBILITY  OF   CHILDREN. 

The  law  of  every  land  concedes  that  a  child  cannot  be  held  respon- 
sible for  criminal  actions :  its  judgment  is  defective,  and  it  does  not 

between  the  habitual  criminal  and  the  insane.  The  annexed  faces  will  suffice  to  prove 
the  existence  of  the  insane  type  among  criminals ;  but  if  any  reader  will  take  the 
trouble  to  consult  Byrnes's  Frofcmonal  Criminals  of  America,  he  will  find  that  the 
majority  of  tliose  habitual  criminals  exhibit  few,  if  any,  signs  of  degeneracy.  For  the 
present  there  is  still  a  wide  gap  between  criminality  and  insanity.  The  entire  ques- 
tion is  cleverly  dealt  with  in  the  book  by  Havelock  Ellis  entitled  The  Criminal.  The 
conclusions  of  the  Italian  school  of  criminology  are  also  criticised  in  the  work  of  Baer 
and  in  the  monogi-aph  of  Hirsch. 

*  For  a  fuller  account  of  each  form  the  reader  is  referred  to  Dr.  Hamilton's  article 
in  this  volume. 


IXSJNITY  AXD    CHIME. 


185 


realize  its  relations  to  the  other  elements  of  the  social  organism;  it 
may  be  able  to  diseriniinate  between  right  and  wrong  in  certain  con- 
crete instances,  bnt  of  the  abstract  principle  of  right  and  wrong  it  has 
no  conception.  The  early  acqnisition  of  snch  knowledge  is,  however, 
the  main  object  of  aU  training. 

The  limit  of  cliildliood  is  fixed  ditferently  in  various  countries.  In 
this  country  responsibility  begins  with  the  foiu-teenth  year.  Lord  Hale 
demanded  that  a  normal  individual  should  have  the  understanding. "  as 
ordinarily  a  child  of  fourteen  years  hath."     Austria  adheres  to  the  same 


Fig.  26. 


-Forger :  receding  forehead  and 
prognatliism. 


Fig. 


.—Bandit :  receding  foi'ehead  and 
liuge  lower  jaw. 


limit,  while  Germany  exacts  full  responsibility  after  the  completion  of 
the  twelfth  year ;  in  France  there  is  no  well-defined  age-limit,  and  ehil- 
di'cn  under  ten  are  not  infrequently  brought  to  court  and  sentenced.  In 
all  civilized  countries  there  is  a  tendency,  however,  to  extend  the  limit ; 
in  France  to  the  age  of  sixteen  years  or  thereabout,  and  in  other  coun- 
tries even  up  to  the  age  of  eighteen  years.  This  is  quite  in  keeping  with 
the  efforts  at  criminal  reform,  and  special  reformatory  institutions  have 
been  established  at  different  places  for  the  care  and  reform  of  youthful 
dehnquents.  Among  the  general  average  of  youthful  criminals  not  a  few 
show  signs  of  a  bad  inheritance. 

The  statistics  of  early  crimes  are  quite  appalling,  showing  the  need 
of  special  legislation ;  according  to  Krafft-Ebing  the  average  number  of 
criminals  under  sixteen  years  in  Prussia  varies  between  5085  and  9225. 
A  very  few  only  of  these  youthful  criminals  are  examined  ■^^dth  reference 
to  their  mental  condition ;  if  such  an  exaniination  were  made  it  is  safe 
to  say  that  a  very  large  number  would  give  undoubted  evidence  of  de- 
fective inheritance,  or  of  deficient  mental  and  moral  training  in  early 
years.  And  this  deficiency  in  training  is  often  in  direct  relation  to  the 
mental  peculiarities  of  parents.  Several  of  the  worst  cases  at  the  Elmira 
Reformatory  have  been  boys  w^ho  were  supposed  to  be  of  normal  mental 
development,  even  bright ;  yet  their  descent  from  hysterical  and  epileptic 
stock,  and  the  poor  training  which  neurotic  parents  gave  them,  were 


186 


A  SYSTEM  OF  LEGAL  MEDICINE. 


Fig.  28. 


Fig.  29. 


Fig.  30. 


Fig.  31. 


Fig.  33. 


Fig.  33. 


Figs.  28  to  33.— Selections  from  sketches  made  by  Dr.  Vaias  Clarke  of  Woking  Prison,  and  re- 
produced in  Ellis'  book. 

Fig.  28.— Dock  laborer,  aged  18:  assault  and  robbery.  Fig.  29.— Farm  laborer,  aged  38 :  hprse- 
tbief.  Fig.  30.— Laborer,  aged  ,21 :  robbery  with  ^^olence.  Fig.  31.— Puddler,  aged  21 :  wounding. 
Fig.  32.— Cook  and  steward:  larceny.  Fig.  33.— Age  25:  robbery  with  violence.  AU  but  one 
(Fig.  31).-had  been  previously  convicted. 


PLATE  III. 


j 

f 
} 


■Jii-.  A. 


Fit?.  B. 


Fi>,'-  C. 


Fii,'.  I). 


CFvIMIXALS  BY  REASON  OF  INSANITY. 

FiK.  A.— Aged  37  years;  killed  Dr.  Lloyd,  a.sylum  physician:  in  love  with  Mary  Anderson: 
declared  "insane  and"  responsible  '"(1);  life  sentence.     Characteristic  pose  of  body. 

Fiii.  B.— Aged  .50  years;  insane  ancestry;  impulses  to  kill  his  children;  murdered  a  police- 
man without  cause.  Hallucinations  and  delusions;  "can  talk  with  mice,  birds,"  etc. ;  melan- 
choly countenance.  TJ!     • 

Fig.  C— Aged  26  years;  murder  in  the  first  degree:  sentence  commuted  to  life  imprison- 
ment; one  terra  at  reformatory;  insane  ancestry.  Is  depressed:  delusions  of  persecution; 
massive  jaws;  dolichocephalic;  exophthalmos:  coronal  suture  depressed. 

Fig.  b.— Aged  Cn ;  shot  at  a  female  church-organist.  Hallucinations  of  hearing  caused  act. 
lity  not  recognized  on  trial.     Says  he  is  "Duke  of  Sussex  and  Earl  of  Beauharnais. 


Insanity 


INSAXITY  AND   CBIME.  187 

directly  responsible  for  the  wrongs  they  committed  *  Growing  np  amid 
such  surroundings  they  could  not  bo  expected  to  discriminate  between 
right  and  wrong  in  the  abstract,  nor  even  between  mine  and  thine. 
Consider  in  addition  that  the  age  of  puberty  is  attended  by  an  awak- 
ening of  the  sexual  sphere,  with  all  that  it  implies  regarding  the  relation 
to  the  opposite  sex — a  period  fraught  with  a  certain  amount  of  danger 
for  every  normal  child  ;  consider,  also,  that  at  this  same  age  all  the  latent 
inheritance  conu's  into  play,  that  the  family  ghosts  (hysteria,  epilepsy, 
insanity)  have  their  say,  and  that  the  hal)it  of  mastui-bation  is  often 
engendered  to  intensity  latent  defects  or  create  new  troubles :  consider 
all  this  and  there  will  be  little  wonder  that  crime  is  so  frequent  in  early 
life. 

Children  have  committed  many  different  crimes.  Murder,  arson,  and 
stealing  are  tlie  comnu)nest  of  these,  all  of  them  the  result  of  defective 
judgment  or  of  defective  training,  or  both. 

S.,  a  lad  of  ten  years,  living  in  Alsace,  had  a  compauion  who,  as  the 
son  of  wealthy  parents,  wore  fine  clothes.  S.  was  envious  of  these.  One 
day  he  induced  his  little  friend  to  go  to  the  woods,  murdered  him,  and 
then  donned  his  fine  clothes,  leaving  his  own  ragged  clothes  at  the  place 
of  nuirder.  He  was  discovered  and  tried.  The  jury  found  that  he  acted 
with  "  discernment,"  and  declared  him  guilty,  but  recommended  him  to 
the  mercy  of  the  court;  he  was  sentenced  to  ten  years  in  prison.  (Mit- 
termaier,  Friedreich's  liJaffer,  1865,  vol.  v.,  quoted  by  Krafft-Ebiug.)  The 
jury  were  evidently  guided  by  the  old  principle  that  if  the  person  knows 
the  nature  of  the  act  he  must  be  guilty.  This  does  not  hold  good  with 
reference  to  adults ;  applied  to  a  child  of  ten  years  it  is  monstrous. 

Last  year  a  boy  of  twelve  years  was  brought  to  me  from  Texas,  who 
had  been  placed  at  a  school  away  from  home  and  lived  with  one  of  his 
teachers.  This  was  evidently  not  to  his  liking.  One  evening  he  asked 
to  be  allowed  to  attend  a  '"' candy-pidl."  The  teacher  refused.  Very 
soon  thereafter  the  boy  walked  into  his  bedroom  ami  deliberately  set  fu-e 
to  the  clothes  in  a  closet.  As  soon  as  the  smoke  was  noticed  he  confessed 
what  he  had  done  and  helped  to  extinguish  the  flames.  The  examination 
of  the  boy  brought  out  the  fact  that  he  was  not  very  l)riglit,  and  that  he 
was  homesick ;  and  that  he  committed  the  act  first  from  a  slight  feeling 
of  spite  toward  the  teacher  and  then  because  he  was  anxious  to  be  sent 
home.  During  a  prolonged  period  of  observation  and  for  months  at 
home  he  has  not  shown  any  evidence  of  insanity  or  of  viciousness. 

Still  another  case  will  illustrate  the  narrow  line  of  demarkation  be- 
tAveen  sanity  and  insanity  in  children,  as  well  as  the  effects  of  faulty 
training.  A  well-developed  girl  of  fourteen,  the  child  of  respecta])le  and 
well-meaning  parents,  was  referred  to  me  some  tinu'  ago  for  an  0})inion 
as  to  her  mental  status.  The  child  had  become  Avillful  and  unmanage- 
able, had  no  regard  for  the  truth,  and  at  school  had  taken  things  out  of 
other  children's  pockets.  In  addition  to  these  unfortunate  qualities  she 
exhibited  considerable  sexual  excitement  and  was  anxious  to  obtain  in- 
formation on  sexual  matters.  By  her  relatives  she  was  supposed  to 
be  precocious,  whic^h  she  was  not  except  as  regards  vicious  habits.  In 
former  days  physicians  would  have  made  a  diagnosis  of  kleptonuinia,  if 

*  In  this  respect  the  medical  reports  of  the  Elmira  Eeformatory  are  of  great  in- 
terest. 


188  ^   STSTE^r  OF  LEGAL  MEDICLXE. 

not  of  moral  insanity ;  bnt  the  cliild,  ttIio  was  descended  from  a  distinctlj^ 
nem-otic  stock,  was  the  victim  of  f aiiltr  training :  in  view  of  her  snpposed 
precocity  she  was  enconi-aged  in  the'  idea  that  what  she  desired  should 
be  hers,  "that  she  was  an  imusnal  child,  etc.  This  young  gii"l  was  placed 
in  the  charge  of  an  intelligent,  sober-minded  teacher,  who  has  studied 
her  mental  peculiarities  and  has  succeeded  in  changing  the  child's  point 
of  ^dew.  In  this  one  instance  the  cooperation  of  physician  and  teacher 
has  averted  impending  mischief :  but  in  dozens  of  other  cases  the  seed 
that  has  been  sown  ripens,  and  aU  sorts  of  crime  result  in  later  years 
fi-om  faulty  inheritance  made  worse  by  faulty  training. 

The  inference  to  be  di-awn  fi'om  'these  few  examples  is  that  even  if 
insanitv  cannot  be  proved  in  a  youthful  criminal,  the  antecedent  history 
and  the  early  education  of  the  child  should  be  taken  into  account,  and 
both  these  may  discover  extenuating  cii'cumstances. 

AEEESTED   OR  DEFECTIVE   DE'S'ELOPJMENT   OF   THE   BRAIN. 

Under  this  heading  are  to  be  included  all  cases  of  insufficient  devel- 
opment of  the  mind  varying  between  idiocy,  imbecihty,  and  mere  weak- 
mindedness.  This  is  a  difference  in  degree  and  not  in  kind  5  a  difference 
in  the  stage  at  which  cerebral  development  was  arrested,  or  a  difference 
in  the  extent  to  which  the  development  of  an  imperfectly  organized 
brain  has  been  carried. 

Idiocy  or  imbecihty  may  be  truly  hereditary,  or  due  to  injmy  dming 
labor,  or' to  influences  which  have  been  active  during  the  earlier  years  of 
life.  Idiocy  fi'om  hereditary  causes  is  most  apt  to  occm-  iu  the  descend- 
ants of  distinctly  nem-otic  stock,  in  families  in  which  insanity  has  occm-red 
in  succeeding  generations,  or  in  those  in  which  epilepsy,  chorea,  hysteria 
have  been  fi-equent  occm-rences :  often  the  parents  themselves  have  been 
thus  affected.  But  two  conditions  lead  more  frequently  than  all  others 
to  idiocy  and  imbecility  in  the  descendants :  the  fii-st  is  alcoholism  of 
either  parent,*  and  the  second  is  blood-relationship  between  man  and 
wife :  it'  there  he  the  slightest  taint  in  the  family  this  taint  is  greatly  in- 
tensified by  such  a  imion.  As  there  are  few  families  entirely  free  from 
such  taints,  the  e^il  of  intermarriages -can  be  easily  gauged. 

A  vers'  considerable  numlier  of  cases  of  idiocy  are  dne  to  diSiciilties 
dm-ing  labor.  To  the  .study  of  this  class  of  subjects  the  present  wiiter 
has  devoted  much  tune  and  lalwr.  The  purely  medical  questions  in- 
volved need  not  lie  alluded  to  in  this  chapter,  but  fi'om  a  forensic  point 
of  viev:  it  is  important  to  know  that  prolonged  labor  and  the  application 
of  the  forceps  to  the  skull  of  the  child  often  cause  a  hemorrhage  over 
one  or  both  halves  of  the  brain ;  that  this  hemori-liage  ultmiately  results 
in  an  atrophy  of  a  considerable  portion  of  the  cortex ;  and  that  this  at- 
rophy may  lead  to  defective  development  of  the  mind.  Let  me  add  at 
once'that'the  law;s'er  and  medical  man  should  not  endeavor  to  prove  too 
much  by  this,  for  in  the  vast  majority  of  cases  prolonged  labor  and  in- 
stinimeiital  delivery  do  little  harm ;  and  if  harm  has  been  done  to  the 
\>Y-Am>pUq)sy  and  jxtrahfsis  (unilateral  or  bilateral)  are  frequently  associ- 
ated u-ith  idiocy  or  imbecility. 

Idiocy  or  imbecility  may  also  be  due  to  external  injmy  (falls)  to  the 
skiill  during  the  early  years,  or  to  the  acute  infectious  diseases  so  com- 
mon in  chiidliood.     Convidsions,  whether  of  reflex  origin  or  the  precur- 

*  Syphilis  is  also  mentioned  by  many,  but  I  doubt  its  significance  in  tins  respect. 


INSANITY  AND   CRIME.  Jgg 

sors  of  an  infectious  disease,  may  be  the  direct  cause  of  arrest  of  brain 
development.  I  have  known  children  of  two  years  and  even  older  to 
become  complete  idiots  after  the  occurrence  of  such  convulsions,  alth(High 
they  were  entirely  normal  ])efore  such  convuLsi(»ns  had  occurred. 

Fiu'thermore,  weak-mindedness  developing-  at  aljout  the  ajj^e  of  pu- 
berty nuiy  l)e  the  result  of  inheritance;  in  these  cases  the  brain  has  Ix-en 
capal)le  of  a  certiiin  amount  of  development,  and  the  symptoms  of  imbe. 
cility  have  not  become  manifest  until  the  work  of  a  normal  adult  brain 
has  been  expected. 

The  jurist  and  the  medico-legal  expert  need  take  but  little  trouble 
to  prove  the  existence  of  idioc}^ :  the  idiot,  as  a  rule,  speaks  for  himself ; 
but  there  are  grades  of  imbecility  wliich  approximate  so  closely  to  the 
normal  tlia.t  it  will  require  some  skill  to  demonstrate  wherein  the  imbe- 
cile is  deficient. 

The  idiot  is  entirely  incapable  of  utilizing  impressions  that  he  has 
received  ;  there  may  be  perception,  but  not  apperception  ;  he  is  restless, 
but  restless  without  a  purpose ;  he  is  animal-like  in  his  appetites,  and 
the  gratification  of  these  is  sought,  at  times,  in  bestial  fashion.  It  is 
needless  to  add  that  the  idiot  exhibits  no  judgment  and  no  memory,  ex- 
cept that  he  is  veiy  apt  to  know  whether  his  appetites  have  been  gratified 
in  the  usual  way. 

The  imbecile  is  distinctly  removed  from  this  order  of  beings,  yet  re- 
lated to  them  clearly  enough.  He  is  capable  of  a  few  al^stract  concep- 
tions, may  learn  to  know  liis  relations,  can  be  taught  to  avoid  danger, 
to  keep  himself  clean,  to  be  quiet  when  strangers  are  around,  and  so 
on ;  but  as  he  grows  the  deficiency  of  his  mental  and  moral  make-up  is 
evidenced  in  the  excessive  development  of  the  animal  appetites.  The 
gratification  of  hunger  and  of  the  sexual  appetite  is  his  most  important 
aim  in  life.  Every  one  has  known  imbeciles  who  coidd  be  made  happy 
l)y  tobacco  or  a  few  drops  of  whiskey.  The  sexual  appetite  is  gratified 
by  self-abuse,  which  soon  increases  the  imbecility,  or  l)y  attempts  at  in- 
tercourse with  all  sorts  of  persons — mth  children  and  old  women  ;  Giraud 
reports  [Ann.  Med.-Psuch.,  1885,  vol.  i.)  the  case  of  an  idiot  who  attempted 
to  rape  his  own  sister.  A  feeling  of  modesty  or  of  shame  is,  as  a  rule, 
entirely  wanting. 

When  all  symptoms  are  distinctly  marked  the  task  of  diagnosticating 
imbecility  is  relatively  easy.  It  is  much  more  difficult  if  the  person  in 
question  exhibits  only  a  moderate  degree  of  iml)ecility ;  in  such  cases  we 
must  be  guided  entirely  by  an  examination  ^\\\h.  reference  to  the  range 
of  the  person's  mental  horizon,  and  1\y  the  account  (always  valuable)  of 
his  behavior  toward  his  relatives  and  in  his  home  surroundings.  A  com- 
parison with  Other  subjects  of  the  same  age  is  important,  but  individual 
differences  must  be  allowed  for.* 

The  idiot  and  the  imbecile  have  defective  judgment  and  cannot,  there- 
fore, be  held  responsible  for  the  acts  they  commit ;  they  may  learn  to 
distinguish  between  right  and  wrong,  but  they  are  deficient  in  the  appli- 

*  A  few  imbeciles  liave  attained  eousiderable  skill  in  some  one  department,  as  me- 
chanics and  even  as  artists ;  tlirongh  carefnl  education  the  original  imbecility  may 
be  covered  np.  Sander  reports  the  case  of  a  young  German  who  passed  his  first  law 
examination  who  was  pronounced  an  imbecile.  I  knew  a  young  t-hemist.  an  evident 
imbecile,  who  had  succeeded  in  passing  his  examination,  but  it  took  him  years  of 
study  to  get  what  others  got  in  a  few  years ;  in  the  struggle  for  existence  he  proved 
an  absolute  failure. 


190  A   SYSTEM  OF  LEGAL  MEDICINE. 

cation  of  sucli  knowledge,  for  their  judgment  and  deficient  reasoning 
are  easily  overrnled  by  their  passions. 

Imbeciles  have  committed  crimes  not  realizing  the  full  consequences 
of  their  actions,  or  from  a  mere  desii-e  to  gratify  their  passions  and  im- 
pulses. Casper  reports  the  case  of  an  idiotic  cannibal  of  forty  years, 
who  was  in  the  habit  of  carrying  about  a  nephew  of  two  years.  One  day 
he  failed  to  return  home ;  he  was  discovered  in  the  woods ;  he  had  bit 
through  the  child's  throat  and  gullet,  had  eaten  its  flesh  and  drank  its 
blood.  His  only  motive  was  that  he  wished  to  eat  the  child's  flesh  in 
order  that  he  might  grow  tall — he  had  no  conception  of  the  enormity  of 
his  crime. 

The  annals  of  crime  and  of  psychiatry  are  full  of  such  cases — none 
more  horrible  than  that  of  Carlino  Grandi,  who  buried  four  children 
alive,  and  was  discovered  when  he  attempted  to  bury  a  fifth.  He  was 
anxious  to  rid  himself  of  boys  who  were  poking  fun  at  him,  and  thought 
it  quite  a  proper  way  to  proceed.  He  thought  that  the  four  boys  who 
were  in  Paradise  were  better  off  than  he.  He  was  sentenced  to  impris- 
onment for  twenty  years. 

Imbeciles  have  so  frequently  been  guilty  of  incendiarism  that  they 
constitute  a  large  percentage  of  pyromaniacs.  The  incendiarism  is  some- 
times the  mere  result  of  a  desire  to  see  a  grand  spectacle,  in  other  cases 
of  a  desire  to  practice  revenge  upon  a  supposed  rival,  and  sometimes 
arises  from  a  mere  spirit  of  restlessness  and  a  desire  to  do  something. 

Whatever  the  nature  of  the  crime  may  be,  it  is  the  duty  of  the  medical 
expert  to  prove  by  the  history  of  the  accused,  and  by  the  result  of  his 
examination,  that  he  presents  distinct  symptoms  of  defective  mental  de- 
velopment. 

DEAF-JIUTISM. 

No  one  would  ordinarily  think  of  classifying  deaf-mutes  with  the 
insane  ;  but  if  they  have  not  been  trained  in  special  schools  they  may  re- 
main entirely  devoid  of  all  moral  concepts,  and  their  social  status  may 
be  not  unlike  that  of  the  imbecile  or  idiot.  Fortunately,  criminal  acts 
by  deaf-mutes  are  very  much  rarer  than  they  were,  owing  to  the  im- 
proved methods  of  instruction.  If  a  deaf-mute  commits  a  crime  it  will 
be  natural  to  question  his  responsibility ;  but  a  decision  can  under  no 
circumstances  be  given  unless  it  is  clearly  proved  whether  he  has  or  has 
not  been  properly  trained,  and  whether  his  mind  has  been  able  to  grasp 
the  ordinary  conception  of  right  and  wrong.  No  one  but  an  experienced 
deaf-mute  instructor  can  be  trusted  to  secure  such  evidence,  or  to  deter- 
mine the  exact  condition  of  his  mind.  Under  the  influence  of  strong 
emotions  during  a  fit  of  frenzy,  deaf-mutes  have  set  fire  to  houses  and 
have  committed  murder. 

Casper  {VierteljahrsscJir.,  vol.  xxii.,  p.  136)  tells  of  a  deaf-mute  twenty- 
four  and  a  half  years  of  age  who  set  fire  to  a  stable  after  he  had  been  struck 
by  his  father,  who  had  been  in  the  halnt  of  abusing  him.  Wliile  the  fii-e 
was  raging  he  clapped  his  hands  with  joy.  On  examination  he  was  found 
to  be  weak-minded,  his  mental  capacity  not  exceeding  that  of  a  boy  of 
fourteen. 

It  is  evident  that  deaf -mutism  aloue  does  not  constitute  an  excuse  for 
crime,  but  that  if  the  person  has  not  been  properly  trained  his  intellect 
and  his  moral  make-up  may  be  defective.     It  is  therefore  of  the  utmost 


IX.SAXiry  AND   CHIME.  191 

iiui)ortaiice  to  determine  the  exact  meutal  eouditiou  independently  of 
tlie  deaf-nuitisni. 

The  condition  of  deaf-mutism  may  be  simulated;  if  so,  the  following 
tests  should  be  iviiiciiibcrcd :  A  deaf-nuite  perceives  the  vil)rations  of 
the  air  caused  by  h)U(l  chipiting  of  the  hands  or  by  stanii)ing  the  floor; 
a  sinndator  will  claim  not  to  notice  this,  nor  to  perceive  the  vibrations 
of  a  tuning-fork  placed  between  the  teeth,  which  a  deaf-mute  perceives 
perfe(;tly.  Deaf-mutes  spell  correctly  as  a  rule,  as  they  have  been  care- 
fully instructed ;  simulators  often  spell  incorrectly,  perhaps  intentionally 
so.  ^  Krafft-Ebing  refers  to  a  method  suggested  to  him  by  Professor 
Kessel.  The  supposed  deaf-mute  is  to  be  placed  in  a  room  and  given 
his  meals  at  regular  intervals.  This  is  to  be  omitted  for  once,  while  in 
an  adjoining  room  the  sound  of  "forks  and  knives"  is  to  suggest  that 
it  is  time  for  his  meal  to  l)e  l)rouglit :  he  will,  in  all  probability,  turn  to 
the  source  of  the  noise.  This  is  ingenious,  but  we  doubt  whether  it  will 
prove  successful  in  all  cases. 

JMELANCHOLIA. 

Melancholia  is  a  well-recognized  form  of  insanity  which  may  become 
the  cause  of  crime.  It  is  not  to  be  confounded  with  simple  melancholy 
depression,  which  may  accompany  almost  any  form  of  mental  disease. 
It  is  as  natural  for  a  lunatic  who  has  delusions  of  persecution  to  be  de- 
pressed and  melancholy  as  it  would  be  for  a  sane  person  who  found  that 
everything  and  everyl:)ody  were  against  him. 

In  true  melancholia  the  depression  is  the  primary  condition.  Without 
cause  or  reason  the  patient  is  in  a  state  of  intense  depression,  out  of 
which  he  cannot  be  argued.  Whatever  his  experiences  may  be,  even 
though  they  might  have  been  a  source  of  pleasiu'e  to  others,  he  is  swayed 
by  the  depressed  mood,  and  will  look  at  the  world  only  through  the  dark- 
ness of  his  own  soul.  His  feelings  are  smothered.  He  takes  no  pleasure 
in  business  or  professional  work ;  music  has  lost  its  charm ;  he  grows 
indilferent  to  every  one,  cares  not  for  wife  or  child ;  he  is  doomed  to  per- 
dition, and  every  one  dear  to  him  is  to  meet  the  same  fate.  A  mother 
once  devoted  to  her  children  feels  that  all  maternal  feelings  have  left 
her ;  that  she  does  not  care  whether  her  childi-en  are  ill  or  well,  whether 
they  are  living  or  dead.  None  but  sad  thoughts  pass  through  the  mind, 
helping  to  intensify  the  original  depression.  A  total  lack  of  energy 
characterizes  such  patients ;  with  this  lack  of  energy  goes  the  idea  that 
there  is  no  use  in  trying  to  do  anything,  for  it  is  bt)und  to  lead  to  evil 
and  to  do  harm  in  the  end.  The  patient  sometimes  perceives  the  slug- 
gishness of  mind  and  body  which  is  so  characteristic  of  this  state,  and 
grows  more  and  more  morbid  over  this  altered  state  of  feeling,  broods 
all  day  long,  becomes  silent  and  totally  indifferent  to  everything.  The 
physical  depression,  the  loss  of  appetite  and  of  sleep,  chronic  constipa- 
tion, soon  affect  his  general  bodily  health,  and  he  becomes  a  pitiable 
l)liysical  and  meutal  wreck ;  but,  fortunately,  in  many  instances  the 
wreck  is  not  complete  and  recovery  may  set  in. 

In  melancholy  there  is  a  distinct  inhibition,  a  ''  slowing  up  "  of  all  men- 
tal and  physical  processes,  but  the  person  thus  afflicted  is  able  for  a  time, 
at  least,  to  examine  his  reasoning  poAvers,  and  will  naturally  try  to  find 
some  cause  for  his  depressed  feelings.     As  a  ride  the  cause  is  supposed 


192  ^  SYSTEM  OF  LEGAL  MEDICINE. 

to  be  within  himself :  he  has  not  done  his  dnty  to  his  next  of  kin,  to  his 
fellow-men ;  he  feels  that  he  is  a  miserable  creature,  that  he  has  been 
guilty  of  gi-eat  sin,  that  he  does  not  deserve  to  live,  bringing  misery  only 
upon  himself  and  his  family.  Mothers  suffering  from  melancholy  de- 
clare that  they  have  not  done  their  full  duty  toward  their  children ;  that 
they  have  been  neglectful  of  their  children's  earl}^  education,  or,  as  a 
patient  of  mine  insisted,  she  did  not  prepare  her  daughter  properly  for 
the  duties  of  married  life,  aud  in  this  committed  a  grave  otfense — ^in 
short,  naught  but  self -accusation.  To  make  the  condition  still  more 
painful,  delusions  and  hallucinations  in  keeping  with  the  depressed  emo- 
tions add  to  the  anguish  of  the  patient. 

For  weeks  and  for  months  the  patient  may  remain  in  this  condition 
of  depression,  showing  no  signs  of  phj^sical  or  mental  activity,  often  not 
uttering  a  word  for  days  at  a  time,  except  possibty  to  bemoan  the  sad- 
ness of  his  or  her  fate ;  but  this  quiet  is  at  times  changed,  and  quite 
suddenly  too,  and  the  violence  of  the  acts  committed  is  often  in  direct 
proportion  to  the  degree  of  former  depression.  The  j)atient  breaks  all 
chains  at  once,  as  it  were. 

The  melaucholiac  is  led  to  deeds  of  \dolence  in  order  to  put  an  end 
to  his  own  sufferings,  to  avert  impending  danger  for  himself  and  others, 
or  in  obedience  to  delusions  and  hallucinations.  A  sudden  fear  is  very 
apt  to  seize  him,  and  in  tliis  condition  he  becomes  thorougiily  irrespon- 
sible. 

Suicide  is  the  natural  effort  of  the  depressed  patient  to  free  himself 
from  misery ;  but  on  this  act  we  need  not  dwell  at  any  length,  for  it  is 
not  a  crime  in  the  eyes  of  the  law,  and  the  question  of  responsibility  is 
not  to  be  argued  with  regard  to  it.  But  cases  of  "  indirect  suicide  "  have 
occurred  which  are  of  the  very  greatest  importance.  Religious  scruples 
have  prevented  many  an  individual  who  was  so  inclined  from  committing 
suicide,  but  as  his  only  wish  is  to  die  he  must  merit  death  in  some  form, 
and  so  commits  miu"der  in  order  that  he  may  be  put  to  death  by  the  State. 

A  young  man  twenty  years  of  age,  without  any  known  cause,  stabbed 
a  young  woman  sitting  next  to  him  in  the  theater ;  she  died  instantly. 
To  her  husband  he  said,  "  I  know  neither  you  nor  yoiu*  wife.  I  do  not 
know  you."  When  cross-questioned  he  explained  that  he  was  tired  of 
life,  Ijut  preferred  to  die  on  the  scaffold,  as  that  would  give  him  time  to 
make  his  peace  with  G-od.  He  had  thought  of  insulting  an  ofl&cer,  of 
killing  a  priest,  of  assassinating  the  president  of  the  French  Eepublic, 
but  all  these  he  did  not  wish  to  kill ;  as  he  entered  the  theater  he  saw  a 
young  gii-1,  but  her  life,  too,  he  spared ;  the  married  woman  sitting  next 
to  him  appeared  to  him  to  be  the  proper  Adctim.  [Gaz.  cles  tribunaux, 
1851.)  Was  ever  murder  committed  more  deliberately?  There  was  no 
doubt  of  his  knowledge  of  right  and  wrong,  but  the  insane  motive  that 
led  to  the  deed  would  not  have  been  suspected  by  any  sane  mind. 

The  ''  desire  to  hang "  is  not  always  the  result  of  a  tcedhim  viUe;  it 
comes  at  times  in  the  form  of  an  uncontrollable  impulse.  Such  was  the 
case  of  the  young  murderer  of  eighteen  years  who  felt  an  ''impulse"  to 
kill  some  one :  he  followed  a  boy,  who  was  the  first  person  he  saw,  to  a 
convenient  place,  and  murdered  him  in  cold  blood,  taking  e^ddent  pleas- 
ure in  the  deed.  He  knew  the  boy  had  no  ill  feeling  against  him,  "only 
I  had  made  up  my  mind  to  murder  somebody."  He  did  it  because  he 
wished  to  be  hanged,     (Maudsley,  p.  158.)     The  boy  was  executed,  and 


INSA^■ITy  AND    CRIME.  193 

the  judge  gave  the  opinion  tliat  he  was  thoronglily  responsil)le,  as  he 
was  al)le  to  understand  the  nature  and  e()nse(|nenees  of  liis  act,  and  that 
he  knew  the  i)unislunent  was  eapital.  This  the  learned  judge  (considered 
a  deeper  aggravation  of  the  erinie. 

But  to  return  to  melanelioly.  In  a  state  of  deep  depression  a  mother 
may  suffoeate  her  child,  either  to  end  its  misery  or  because  the  impulse 
suddenly  comes  upon  her  to  change  her  own  condition ;  she  feels  that  she 
must  do  something  in  obedience  to  an  ovei-powering  suggestion.  Re- 
morse and  horror  follow  quickl}'-  upon  the  commission  of  the  crime. 
Eveiy  one  can  recall  recent  cases  in  which  a  mother  has  poisoned  her 
children  to  keep  them  out  of  miserly,  or  has  shot  them  to  j^ut  them  out 
of  harm's  way. 

Melancholy  patients  are  often  under  the  influence  of  intense  fear : 
they  feel  that  something  terrible  is  certain  to  happen,  that  they  must 
act  to  meet  the  impending  danger.  The  pent-np  feelings  are  finally  let 
loose,  and  in  a  state  of  raptus  melanclwlkus  a  horrible  crime  may  be 
committed. 

From  a  forensic  point  of  view  the  question  arises  whether  or  not  such 
persons  should  be  permanently  condemned  to  an  asylum.  That  the  per- 
son is  not  responsible  for  deeds  committed  goes  without  saying ;  but  this 
is  a  curable  form  of  insanity,  and  for  years  and  years  not  a  sign  of  in- 
sanity need  be  exhibited.  For  a  period  of  at  least  several  years  after 
the  commission  of  a  crime  the  patient  should  be  carefully  guarded  and 
observed ;  but  after  such  a  reasonable  period  it  would  seem  just  to  give 
such  person  full  liberty,  but  as  a  further  safeguard  the  lunatic  should  be 
placed  under  medical  surveillance  for  a  period  of  at  least  five  years,  and 
with  the  first  indication  of  a  relapse  should  be  returned  to  the  asylum 
for  treatment  and  safe-keeping. 

JIANIA. 

The  term  ''mania"  is  used  to  denote  a  form  of  mental  disease  which 
is  the  direct  opposite  of  melancholia.  The  sense  of  the  word  was  per- 
verted in  the  days  of  monomanias ;  in  modern  psychiatry  it  represents 
the  chiss  of  cases  now  to  be  described. 

In  contrast  to  the  inhibition  and  slowing  up  of  all  cerebral  and  phys- 
ical functions  in  melaiK'holy,  there  is  in  mania  a  decided  acceleration  of 
these  functions,  associated  with  a  feeling  of  Avell-being.  Far  from  lieing 
-depressed  and  without  energy,  the  maniac  is  in  an  exalted  mood,  ready 
and  able  (so  he  thinks)  to  do  anything :  to  win  in  any  struggle,  to  down 
all  enemies,  and  to  accomplish  with  ease  what  the  timid  (the  sane)  dare  not 
attempt.  This  exalted  state  of  feelings  leads  to  excesses  and  reckless- 
ness :  he  is  apt  to  be  on  the  go,  traveling  from  one  place  to  another ; 
goes  about  from  club  to  club ;  indulges  himself  to  excess ;  di'inks  fre- 
quently; and  in  the  full  vigor  of  manhood  worships  to  excess  at  the 
shrine  of  Venus,  and  boasts  of  his  sexual  performances. 

The  psychic  processes  being  accelerated,  or,  rather,  all  inhibition 
being  removed,  he  becomes  fluent  of  speech ;  speaks  on  every  possible 
occasion,  sometimes  sense,  more  often  nonsense ;  the  association  of  ideas 
is  not  under  restraint;  he  passes  from  one  topic  to  another  without  logi- 
cal sequence  ;  like  a  child,  mere  sound  is  apt  to  suggest  new  lines,  not  of 
thought,  but  of  talk,  and  in  manv  instances  he  begins  to  talk  in  rhyme. 


194  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

He  mistakes  his  doggerel  for  true  poetry,  and  recognizes  liis  OTvn  superior 
gifts. 

Witli  the  removal  of  that  inhibitory  restraint  which  keeps  ns  all 
Avithin  bonnds,  the  maniac  yields  to  every  impulse,  and  will  go  to  any 
length  to  satisfy  his  apj)etite  or  liis  ambitions.  He  will  seek  the  highest 
position  within  the  gift  of  the  peo23le,  or  will  endeavor  to  establish  sexual 
relations  with  women  whom  no  one  else  would  dare  to  approach  (delu- 
sions of  grandem-).  If  crossed  in  his  j^lans  he  loses  his  temper,  and  often 
passes  into  a  state  of  uncontrollable  passion.  His  brain  is  in  a  constant 
tiu-moil ;  he  loses  sleep  and  appetite,  and  soon  becomes  exhausted  from 
physical  excesses,  from  overinclulgence  in  sexual  intercoui'se  and  in  the 
use  of  tobacco  and  alcoholic  drinks. 

The  condition  pictiu*ed  above  may  last  for  years  in  a  more  or  less 
pronounced  fashion ;  such  patients  often  pass  for  men  of  unusual  activ- 
ity and  capacity  until  the  difference  between  intention  and  actual  per- 
formance becomes  apparent.  If  such  a  condition  overtakes  a  man  who 
was  formerly  slow  to  arrive  at  conclusions,  cautious  and  sober  in  his 
judgments,  the  change  will  be  recognized  by  every  one.  At  times  this 
same  patient  'will  be  able  to  give  excellent  motives  for  apparently  rash 
acts,  motives  which  the  sane  coidd  not  have  advanced,  and  yet  seem 
reasonable  enough.  (This  special  fonn  is  termed  by  the  French,  writers 
folie  raisonnanfe.) 

The  exalted  mood  of  mania  may  become  intensitied  and  will  then  lead 
to  the  state  of  frenzy,  in  wliich  the  person's  will  knows  no  restraint ;  he 
becomes  violent,  destroys  ever^-thing,  does  bodily  injmy  to  himself,  and 
will  be  liable  to  injiu-e  any  one  else  who  crosses  his  path  while  he  is  in 
this  state. 

The  maniac  comes  into  conflict  with  the  law  by  reason  of  his  exalted 
mood  and  the  extreme  mental  and  physical  restlessness.  At  first  he  in- 
dulges himself  in  private ;  as  the  disease  increases  the  maniac  loses  the 
ordinary  regard  for  public  morals,  will  attack  the  opj)Osite  sex  on  the 
street,  will  try  to  rape  young  children  or  to  mastui'bate  in  public.  If 
opposed  in  the  execution  of  his  plan  he  becomes  quarrelsome  and  is  only 
too  quick  in  the  use  of  fu'earms ;  in  the  spirit  of  restlessness,  and  in 
obedience  to  transitory  delusions  or  hallucinations,  he  ^viH.  commit  arson, 
or  murder. 

Mania  as  well  as  melancholy  often  represent  the  initial  stages  of 
more  chronic  forms  of  mental  disease,  and  often,  too,  are  entirely  ciu-able. 
The  person  who  has  been  guilty  of  a  criminal  act  during  the  period  of 
exaltation  or  maniacal  frenzy  may  ha^^e  fully  recovered  by  the  time  he 
is  brought  to  trial.  The  j^hysiciau  must  therefore  endeavor  to  show  by 
a  careful  history  of  the  case  that  the  patient  was  actually  deranged  at 
the  time  he  committed  the  act.  The  plea  of  transitory  mania  or  tempo- 
rar}"  insanity  is  often  advanced  in  cases  in  which  there  is  insufiicient  rea- 
son for  doing  so.  A  distinction  should  be  made  between  sudden  extreme 
passion  and  maniacal  frenzy.  To  prove  the  latter,  e^ddence  should  be 
brought  forward  to  prove  derangement  before  the  commission  of  the 
criminal  act,  for  maniacal  frenzy  is  never  developed  with  great  sudden- 
ness, and  he  who  knows  how  to  question  and  examine  the  accused  or  his 
relatives  will  be  able  to  prove  the  existence  of  insanity  before  the  act,  if 
any  such  existed.  Such  cases  are,  on  the  whole,  easily  recognized;  a. 
single  example  wiU  suffice  to  illustrate  its  relation  to  crime : 


JXSJXITY  AND    LltlME.  105 

Dr.  Koster,  in  the  Irrenfreund  for  1875,  relates  the  case  of  a  man 
twent3'-nine  years  of  Hi^a,  who  had  an  insane  niothei',  and  who  had  him- 
self alvva3's  been  distin(;tly  neurotic.  ^Marrying  a  woman  much  older 
than  himself,  he  was  guyed  by  his  neighbors,  and  became  scnisitive  to 
then-  remarks.  One  evening  he  was  aecu.scd  of  n(;t  being  the  father  of 
his  chikl.  This  excited  him  intensely;  he  was  unal)]e  to  win-k  and  be- 
came confused.  Two  days  later  he  paced  the  floor  until  twelve  o'clock 
iit  night,  and  at  two  o'clock  ran  to  his  neighbors  dressed  in  his  night- 
sliirt,  telling  them  that  he  had  murdered  his  wife  and  child.  He  had 
choked  his  wife  and  cut  the  throat  of  the  child.  He  spoke  in  a  confused 
manner  of  electricity,  of  satirical  verses  pointed  at  him,  and  was  e^•i- 
tlently  subject  to  deliria  and  hallucinations  of  a  mild  order.  This  con- 
dition lasted  for  uearl}^  six  months,  when  he  slowly  regained  his  mental 
balance.  Tliis  case  proves  how  easily  a  person  with  a  marked  hereditary 
taint  can  pass  into  maniacal  frenzy,  goaded  into  the  condition,  as  it  were, 
by  relatively  slight  causes. 

PARANOIA. 

The  jurist's  and  the  layman's  %dew  of  insanity  is  represented  best  by 
paranoia.  In  this  form  of  mental  disease  delusions  and  hallucinations 
play  a  very  important  part,  whei-eas  we  have  had  little  to  say  about  them 
in  the  other  forms  previous!}'  mentioned.  In  paranoia  the  delusions  and 
hallucinations  are  primary  symjjtoms,  and  not  engendered  on  the  soil 
of  exalted  or  depressed  emotions,  as  in  mania  and  melancholia.  These 
delusions,  "  fixed  ideas,"  become  systematized.  They  are  the  pivot  about 
which  the  entire  personality  and  the  person's  entire  universe  turn.  They 
lead  to  the  formation  of  an  alter  ego,  altogether  different  from  the  original 
ego.  The  delusions  dominate  the  mental  actiWty  to  such  an  extent  that 
they  become  the  mainspring  of  all  action.  The  paranoiac  is  not  amen- 
able to  ordinary  reasoning,  and  his  delusions  cannot  l)e  dislodged  l)y  any 
power  of  logic.  His  mind  is  not  susceptible  to  argument,  for  if  it  were, 
the  delusion  would  of  itself  disappear,  as  the  temporary  delusions  of  the 
sane  or  of  the  curable  insane  do.  He  may  have  one  set  of  delusions,  he 
ma}^  have  many :  the  persistence  of  one  or  of  many  proves  that  the  entire 
logical  apparatus  is  out  of  gear.  It  is  absurd,  therefore,  to  claim  that  a 
person  is  insane  on  some  one  point,  and  one  point  only ;  he  may  show 
his  insanity  in  one  way  onl}',  but  his  mental  derangement  is  as  gi-eat  as 
though  he  had  dozens  of  fixed  ideas. 

Paranoia  is  also  the  most  tj^^ieal  form  of  insanity,  inasmuch  as  it 
shows  most  distinctly  the  effect  of  heredity.  The  fii'st  signs  of  the  in- 
sane neurosis  can,  as  a  rule,  be  traced  far  back  into  childliood.  The 
children  who  ai-e  exchisive,  who  nevei"  care  to  play  with  other  childi-eu, 
who  are  unusually  irritaljle,  who  prefer  to  pray  when  others  go  to  play 
— these  are  the  very  ones  who  develop  paranoia  later  in  life.  Moody, 
irritable,  queer,  and  ''  cranky,"  they  go  along  well  enough  until  they  have 
to  rub  up  against  others  in  the  struggle  for  existence,  or  until  they  are 
overcome  by  some  severe  grief,  by  strong  emotion,  by  political  or  relig- 
ious excitement  (election  campaigns,  re\ival-meetings,  and  the  like) ;  and 
then  delusions  which  may  have  been  latent  for  a  long  time  come  to  the 
foreground.  On  further  inquir}-  into  the  antecedent  history  of  tlie  para 
noiac,  he  will  be  found  to  come  of  neurotic  stock,  in  which  insanity 


196  J   SYSTEM  OF  LEGAL  MEDLCLXE. 

liysteria,  epilepsy,  and  clu'ouie  aleoliolism  have  iDeen  common  oecmTences  ^ 
in  other  cases  a  fall  early  in  life,  a  severe  infections  disease,  such  as 
t^'phoid  fever  or  pneumonia,  or  mastiu-bation,  may  appear-  to  have  been 
the  dii-ect  exciting  cause.  WTiile  the  disease  begins  in  early  life,  the  full- 
fledged  delusions  do  not,  as  a  ride,  appear  until  the  age  of  pubert}',  or 
possibly  not  untd  the  climacterium. 

The  systematized  delusions  of  paranoia  may  be  di^4ded  into  tTro 
great  groups  :  fii"st,  delusions  of  persecution  ;  ancl  secondly,  delusions  of 
grandeui';  the  latter  may  again  be  subdi\-ided  into  religious,  pohtical^ 
and  erotic  delusions. 

Paninoia  ivifh  Delusions  of  Fersecufion. — The  patient  thus  affected 
supposes  himself  to  be  the  victim  of  cii'cumstances,  of  an  indi^'idual,  or 
of  a  corporate  body.  The  essence  of  his  belief  is  that  he  is  made  ta 
suffer  for  wrongs  which  he  has  committed,  or  for  en^y  which  others  feel 
towai-d  him.  He  has,  as  a  rule,  been  morose,  exclusive,  and  perhaps 
given  to  mastm-liation.  He  feels  that  he  is  being  observed  by  others ; 
tliat  the^'  notice  a  peculiarity  in  him ;  that  they  can  read  and  conti'ol  his 
thoughts;  that  the  newspapers  dii-ect  theii'  flings  at  him — when  they 
speak  of  rascals  or  of  thieves  they  mean  him.  Before  long  he  hears 
voices ;  these  are  the  voices  of  his  enemies,  who  ai"e  trying  to  ferret  out 
his  actions ;  he  stops  up  the  keyholes  and  di-aws  the  blinds  of  his  win- 
dows; but  his  neighbors  are  just  outside  and  lying  in  wait  for  him;  if 
they  cannot  get  rid  of  him  as  easily  as  they  wish,  they  put  poison  in  his 
food,  which  he  will  refuse  to  take  from  that  time  on.  He  may  be  the 
\*ictDn  of  socialists,  of  the  poHce,  of  a  definite  religious  sect,  who  will 
endeavor  to  influence  him  by  electricity,  through  the  telephone,  through 
hj-pnotism,  or  to  kill  him  by  causing  him  to  inhale  all  sorts  of  noxious 
vapors.  An  endless  variety  of  delusions  and  of  combinations  of  delusions 
and  haUucinations  may  be  the  result ;  but  the  one  f  eatiu'e  of  all  is  that 
the  patient  is  made  the  victim,  the  sufferer. 

A  ]3atient  of  mine,  twenty-five  years  of  age,  who  had  always  been 
morose,  was  suddenly  seized  with  the  fancy  that  an  intimate  fiieud  of 
his  had  gained  full  control  over  his  mind  and  prevented  the  free  exercise 
of  his  will.  One  day  he  bought  a  j^istol.  which  he  loaded  and  started 
out  to  find  this  friend  and  kill  him ;  but  fortunately  the  fiiend  was  out 
of  town.  As  a  measiu'e  of  safety  he  was  placed  in  an  asylum,  and  was 
kept  there  nearly  two  years.  In  the  asylum  I  examined  the  patient, 
found  him  rational  in  every  way,  and  ordered  his  release  on  trial.  I  in- 
sisted on  his  reporting  to  me  regidarly,  which  he  did  faithfully  enough. 
After  several  months  he  i-emaincd  away,  when,  to  my  chagTin,  I  discov- 
ered that  he  suspected  his  mother  of  beiug  in  conspiracy  against  him^ 
and  that  he  meant  to  '•  fix "  her  for  it.  He  had  to  be  removed  to  an 
asylum  at  once,  where  he  wOl  necessarily  remain  for  a  long  period  of 
time. 

It  is  easy  to  see  that  these  patients  are  a  source  of  great  danger  to 
the  community  at  large ;  there  is  no  telling  whom  they  may  suppose  to 
be  the  cause  of  all  theii-  misery,  and  against  whom  they  may  proceed 
■uith  murderous  intent. 

Moved  by  their  delusions,  and  regarding  them  as  real,  they  act  in 
self-defense ;  for  that  reason  they  commit  deeds  of  violence  on  the  open 
highway,  in  public  places,  and  in  private  houses :  they  have  no  fear  of 
the  result,  and  often  glory  over  then'  supposed  victories.     They  discrim- 


INSANITY  AND   CHIME.  197 

iiiate  between  individuuls,  killing  only  tliose  persons  whom  they  snspect, 
while  passing"  others  by :  the  law,  in  its  great  wisdom,  considers  this 
evidence  of  gnilt,  for  it  proves  premeditation  and  a  knowledge  of  the 
wrong  he  committed. 

The  delnsion  of  "  m;u-ital  infidelity  "  comes  under  this  heading,  particu- 
larly if  it  occurs  in  a  woman,  while  suspicion  of  infidelity  on  the  part  of 
the  wife  is,  as  a  rule,  an  accompaniment  of  chronic  alcoholism  in  the 
husband.  In  the  wife  such  niifontidcd  suspicious  are  the  expressions  of 
a  })aranoia  persecutoria  as  it  occurs  during  the  climacterium.  The  dind- 
inition  of  sexual  concourse,  the  waning  powers  of  fascination,  naturally 
suggest  that  the  husband  or  wife  seeks  gratification  elsewhere.  He  be- 
trays his  relations  to  other  women  by  the  fact  that  he  coughs  when  he 
passes  them  on  the  street.  Tlie  maid  waiting  at  the  table  passes  the 
dishes  with  special  deference  to  the  master  of  the  house.  An  old  lady 
of  sixty  accused  her  husl)and  of  nearly  seventy  of  such  illicit  relations 
with  the  maid.  The  husl  )and  declared  to  me  emphaticall}'  that  he  desired 
no  further  intercourse  with  any  one,  and  that  all  he  cared  for  was  to  go 
to  sleep.  But  the  delusion  persisted,  and  for  a  time  quiet  was  restored 
by  banishing  all  female  help  from  the  house  except  the  cook,  and  the 
old  lady  guarded  the  kitchen  very  carefully. 

In  other  cases,  again,  these  changes  in  the  sexual  sphere  lead  to  the 
delnsion  that  the  person  has  been  raped  in  her  sleep  (whence  false  accu- 
sations), or  that  she  has  been  led  to  houses  of  prostitution  and  the  like ; 
that  others  are  spreading  such  reports  for  the  purpose  of  defaming  her. 
Some  feel  called  upon  to  prosecute  tlie  offenders  in  court  as  a  matter 
of  self-defense. 

Physicians  play  an  unenviable  role  in  some  cases.  A  vaginal  exam- 
ination is  said  to  have  terminated  in  sexual  intercom-se,  or  possibly  to 
have  been  the  cause  of  a  change  in  sexual  feelings.  Phj^sicians  also  play 
a  part  in  mau}^  delusions  of  jiersecution ;  above  all  are  they  frequently 
supposed  to  have  gained  complete  mastery  over  the  minds  of  the  insane, 
and  to  be  in  a  conspii'acy  against  them.  A  pa.tient  of  mine  imagined 
that  I  had  been  engaged  hj  the  family  to  rid  them  of  him,  and  that  after 
his  death  I  was  to  come  in  for  a  share  of  his  fortune. 

Paranoia  with  Delusions  of  Grandeur. — In  this  form  Ave  may  classify 
all  those  cases  in  which  the  subject  imagines  himself  called  upon  to  fulfill 
some  special  mission.  It  includes  the  class  of  insane  political  reformers, 
of  religious  fanatics,  of  emperors,  kings,  and  presidents,  and  those  bent 
on  soTue  special  mission  of  love.  In  all  of  these  there  is  an  exalted  state 
of  feeling  such  as  is  characteristic  of  delusions  of  grandeur.  Those  who 
find  special  pleasure  in  minute  subdivisions  may  establish  the  following 
forms  :  pai-anoia  ref onnatoria  sen  politica ;  paranoia  religiosa ;  paranoia 
erotica. 

The  political  conditions  of  the  present  day  are  such  as  to  arouse  the 
dissatisfaction  of  nuiiiy  living  in  monarchical  countries  as  well  as  in  re- 
publics. The  sane  endeavor  to  right  such  defects  by  the  ballot  and  other 
peaceful  measures.  The  insane,  who  wish  to  bring  about  great  reforms, 
to  entorce  their  own  pet  (generally  foolish)  schemes,  are  anxious  to  strike 
at  once  at  what  they  suppose  to  be  the  root  of  the  evil,  and  theref<u-e  aim 
at  kings,  presidents,  prime  ministers,  and  other  high  officials.  If  their 
own  personal  greed  or  desire  for  advancenu'nt  has  not  been  gratified, 
they  have  an  additional  incentive  to  acts  of  violence.    In  this  connection 


198  ^   SYSTEM   OF  LEGAL  MEDICINE. 

the  ease  of  Gruiteau  overshadows  all  others.  If  ever  there  was  a  pro- 
nounced Innatic  it  was  he ;  yet  he  was  hang-ed  to  satisfy  the  public  con- 
science. The  case  is  too  well  known  to  be  given  in  detail ;  but  let  us 
pick  out  a  few  of  the  salient  points  which  prove  his  insanity. 

Guiteau  was  about  forty  years  of  age  at  the  time  he  shot  Garfield ; 
his  father  was  an  eccentric  individual  who  believed  in  free  love,  in  mes- 
merism, and  believed  himself  to  be  ordained  by  God  to  exercise  these 
functions ;  an  uncle  was  insane  ;  his  mother  had  a  brain  trouble  at  the 
time  of  his  bii-th ;  his  sister  suffered  from  epilepsy  and  puerperal  mania. 
He  had  no  sort  of  sj^stematic  education,  but  was  fond  of  reading,  and 
particularly  on  religious  subjects  ;  he  masturbated  at  very  early  age,  and 
entered  the  Oneida  Community  at  the  age  of  nineteen.  At  the  age  of 
twenty-four  he  writes  to  his  father,  saying  that  he  proposed  to  edit  a 
journal  for  the  special  glory  of  Christ,  and  that  thereafter  churches 
would  not  be  needed ;  that  he  was  employed  by  Jesus  Christ  &  Co.  He 
endeavored  to  study  law,  but  failed.  At  the  age  of  twenty-eight  he  mar- 
ried a  worthy  woman,  whom  he  abandoned  after  four  years  to  live  with 
a  prostitute.  At  the  age  of  thirtj^-four  he  offered  to  secure  the  Presidency 
for  a  foreigner,  if  that  person  would  lend  him  $200,000.  In  this  same 
year  (1875)  he  attempted  to  kill  his  sister,  without  any  sufficient  reason. 
He  continued  to  preach  at  religious  meetings,  and  denounced  theaters. 
During  the  election  campaign  he  wrote  a  short  article  favoring  Gar- 
field's election,  and  imagined  it  to  have  been  chiefly  instrumental  in  his 
election.  He  felt,  therefore,  that  he  was  entitled  to  some  office  ;  aspired 
to  the  consulate  at  Paris,  which  he  and  the  rich  woman  he  was  to  marry 
would  represent  worthily.  Finding  himself  thwarted,  he  conceived  the 
idea  of  murdering  the  President,  and  brooded  over  this  (which  he  gradu- 
ally conceived  to  be  a  political  necessity)  for  six  we^ks  before  proceeding" 
to  the  act ;  he  borrowed  the  money  to  buy  the  pistol ;  acted  with  great 
deliberation,  and  on  one  occasion  when  the  President  was  with  his  M'ife 
desisted  from  shooting,  and  waited  his  opportunity  until  he  was  able  to 
find  him  alone.  After  the  shooting  he  issued  a  letter  to  General  Sher- 
man, in  which  he  tried  to  justify  the  murder  from,  a  sense  of  duty  toward 
the  American  people,  and  as  a  punishment  for  destroying  the  Republican 
party.  His  entire  behavior  on  trial  after  he  was  pronounced  guilty  and 
as  he  was  led  to  the  scaffold  was  that  of  a  man  who  believed  himself 
destined  to  fulfill  a  special  political  mission,  who  was  morbidly  conceited, 
and  who  reveuged  himself  for  the  neglect  of  his  rightful  ( ? )  claims.  It 
was  the  cruel  revenge  of  a  confirmed  lunatic,  of  a  paranoiac  with  delu- 
sions of  grandeur.  (See  Folsom,  Boston  Medical  and  Surgical  Journal, 
February  16,  1882.) 

But  tlie  learned  judge  evidently  thought  otherwise  and  charged  ac- 
cordingly:  *  "If  you  find  .  .  .  that  he  Irad  j^ossessi  on  of  his  faculties,  and 
the  power  to  know  that  his  act  was  wrong,  and  of  his  own  free  will  de- 
liberately conceived,  planned,  and  executed  this  homicide,  then  whether 
liis  motive  was  personal  vindictiveness  or  political  animosity,  or  a  desire 
to  avenge  a  supposed  political  wrong,  or  a  desire  for  notoriety,  or  fan- 
ciful ideas  of  patriotism  or  of  the  divine  will,  or  you  are  unable  to  dis- 
cover any  motive  at  all,  the  act  is  simply  murder,  and  it  is  your  duty  to 
find  him  guilty."    The  jury  obeyed  the  charge,  decided  that  Guiteau  was 

*  Lawson,  p.  188. 


IXSJXITV  AM)    CHIME.  ]  99 

in  full  jwssessioii  of  his  jaculties^  and  foniid  liijii  guilty.  The  judge 
tluuiked  the  jury,  and  modern  psyeliiatry  noAV  records  tliis  case  as  fur- 
nishing- the  l)cst  p()ssi])le  evidence  of  the  inability  of  judge  and  jury  to 
recognize  a  diseased  mind. 

EPILEPTIC  INSANITY. 

Epikpsy  is  a  well-known  convulsive  disorder  characterized  by  seiz- 
ures of  violent  motor  (clonic  and  tonic)  contractions  of  some  or  all  of  the 
muscles  of  the  body.  The  attacks  are  of  short  duration,  but  extremely 
violent  while  they  last ;  between  the  attacks  there  is  a  free  interval  of 
varying  duration.  The  attacks  may  occur  at  intervals  of  months,  weeks, 
days,  or  of  hours  only.  The  disease  is  a  chronic  one,  beginning,  as  a 
rule,  either  in  the  earlier  years  of  life  or  at  the  time  of  puberty  \x\)  to 
the  ages  of  twenty-five  or  thirty  years.  Stric^tly  speaking,  epilepsy  is  not 
so  much  a  disease  per  se  as  a  group  of  symptoms  resulting  from  many 
ditferent  causes ;  anu)ng  these  iiihei-i fanes  was  formerly  considered  to  play 
the  most  important  part.  While  there  is  some  disagreement  on  this  head, 
epilepsy  in  the  ancestry,  chronic  alcoholism  of  the  parent,  or  even  severe 
neuroses  such  as  hysteria  and  chorea,  are  apt  to  lead  to  epilepsy  in  the 
descendants.  Frequently  enough  the  disease  is  accpiired  in  earlier  years 
as  a  result  of  traumatism  during  labor,  of  early  infantile  diseases  (such 
as  scarlet  fever,  pneumonia,  cerebrospinal  meningitis,  etc.),  or  of  direct 
injury  to  skull  and  brain. 

Unfortunately  the  epileptic  attacks,  if  long  continued,  become  asso- 
ciated with  mental  changes,  chief  among  which  are  impidsive  actions  of 
great  violence  at  about  the  time  of  an  attack,  or  as  an  equivalent  of  a 
motor  convulsion ;  a  psj^chic  explosion  may  take  the  place  of  an  ordinary 
motor  discharge.  Such  actions  are  often  committed  in  a  semi-conscious 
or  wholly  unconscious  state,  and  the  epileptic  who  has  committed  an 
outrageous  murder  has  been  found  asleep  by  the  side  of  his  victim,  or 
as  the  epileptic  seizure  j)asses  away  awakens  to  a  full  sense  of  the  atro- 
<jious  crime  he  has  committed.  The  act  of  the  epileptic  generally  bears 
the  imprint  of  a  great  sudden  impulse.  Lomln-oso  has  tabulated  the 
records  of  297  epileptic  prisoners,  and  of  these  76  were  imprisoned  for 
nnu-der.  The  statistics  of  Baer  (p.  300)  are  much  more  favorable,  but  it 
is  quite  evident  tliat  relatively  few  epileptics  were  turned  over  to  his 
institution. 

Epilejisy  is  uncommonly  frequent  in  criminals,  and  the  reason  is  not 
far  to  seek:  in  the  criminal  classes  there  is  a  distinct  tendency  to  the 
severer  neuroses,  of  which  epilepsy  is  one ;  alcoholism  is  a  powerful  etio- 
logical factor,  *  and  among  these  classes  alcoholism  is  the  rule ;  and  in- 
juries to  the  head  are  also  frequent  enough  as  a  result  of  direct  blows  or 
of  falls  in  childhood  due  to  carelessness.  The  epileptic  boy  is  unable  to 
attend  school,  cannot  retain  positions,  and  thus  falls  an  easy  victim  to 
bad  associates.  But  the  criminal  actions  of  an  ei.)ileptic  are  not  neces- 
sarily the  result  of  his  disease,  though  the  disease  and  the  criminal  tend- 
encies may  both  result  from  faulty  inheritance  and  faulty  training. 
Crimes  committed  in  an  epileptic  paroxysm  are  signalized  by  great  sud- 

*  Dejevine  states  that  in  37.7  percent,  of  350  epileptics  the  father  was  a  drunkard. 
{L' Hcrcdite  (hois  leu  jilaladics  (In  JSi/atenie  Nerveux,  p.  115.) 


200  ^   SYSTEM  OF  LEGAL  MEDLCIXE. 

denness  and  violence  of  impulse  5  theii'  cliaracter  suggests  tlie  equivalent 
or  force  of  a  motor  explosion. 

It  is  not  an  easy  matter  to  prove  epilepsy,  for  in  nine  cases  out  of 
ten  the  diagnosis  rests  on  hearsay  e\ddence.  The  attacks  are  extremely 
short,  and  the  physician  rarely  enough  (except  in  iDublic  institutions)  sees 
the  attacks ;  he  has.  therefore,  to  depend  upon  the  description  given  him 
by  competent  attendants  or  observant  laymen.  In  a  genuine  attack 
there  are  sudden  loss  of  consciousness;  the  ej)ileptic  avj-.  convulsive 
movements  of  one  or  all  parts  of  the  body :  biting  of  tongue,  with 
bloody  froth  at  mouth :  involuntary  mictimtion ;  relaxation  of  all  mus- 
cles, followed  by  sound  sleep ;  the  entu'e  cou^iilsive  jDC'i'lod  is  of  very 
short  diu-ation.  There  are  but  few  tangible  symj^toms  of  the  disease  to 
be  made  out  during  the  interval — the  verj-  time  in  which  it  is  often 
desii-able  to  determine  whether  or  not  a  person  has  epilepsy.  As  slight 
evidence  of  the  existence  of  this  disease  we  may  regard  the  traces  of 
laceration  of  the  tongue  diu'ing  the  attack ;  but  a  few  days  after  an 
attack  these  may  not  be  visible.  The  e\'idences  of  bromism  suggest  that 
the  drag  may  have  been  given  for  the  disease,  but  such  evidence  must  be 
accepted  very  guardedly.  3Ioreover,  the  epile^Dtic  attack  has  been  simu- 
lated so  perfectly  that  the  most  careful  observers  have  been  deceived.* 

Sander  (Geisfessfoning  u.Yerhrechen.  p.  236)  relates  the  interesting  case 
of  an  ei^ileptic  aged  twenty-nine,  who  was  arrested  several  times  in  suc- 
cession for  creating  great  distui'bances  on  the  streets  of  Berlin,  of  which 
he  was  only  partly  conscious,  and  for  \iolence  against  policemen  and 
others  who  attempted  to  subdue  him — evidently  a  condition  of  epileptic 
mania.  This  same  epileptic  was  charged  by  his  mother  with  criminal 
violence,  breaking  evein-thing  in  the  household  that  he  could  fasten  upon, 
and  assaulting  his  mother.  When  charged  with  this  he  was  ignorant  of 
much  that  had  passed,  and  did  not  remember  that  a  policeman  was  pres- 
ent in  his  mother's  house.  At  a  later  period  he  attempted  to  choke  his 
mother  in  a  maniacal  attack.  Epileptic  violence  and  forgetfidness  are 
well  illustrated  in  this  man. 

It  is  important  to  remember  that  if  epilejDsy  is  long  continued  a  con- 
dition of  mental  imbecihty  or  dementia  is  developed,  diu-ing  which  im- 
moral or  criminal  actions  are  possible :  furthermore,  states  of  double 
consciousness  occiu-  in  epileptics,  not  unlike  the  ease  of  Dr.  Jekyll  and 
Mr.  Hyde ;  and  for  criminal  acts  committed  diuing  the  states  of  altered 
consciousness  the  accused  can  hardly  be  held  responsible. 

MOR.VL   IXSAXITY. 

Alienists  have  waged  a  hot  battle  over  the  question  whether  there  is 
or  is  not  such  a  disease  as  moral  insanity.t  That  a  condition  exists  in 
which  defect  or  per\-ersion  of  the  moral  sense  is  the  most  prominent 
symptom  there  is  no  doubt,  but  the  best  authors  of  the  present  day  are 
agreed  that  there  is  no  one  disease  characterized  solely  or  even  chiefly 
by  the  deficiency  in  the  moral  sphere  without  impaii'ment  of  the  intel- 

*  This  is  the  famous  case  of  tlie  "  duraray-chucker, ''  who  had  studied  epilepsy  in 
prisons,  and  was  able  to  imitate  the  epileptic  attack  perfectly.  He  would  feign  an 
epileptic  attack  on  the  streets,  and  while  the  crowd  stood  aroimd,  his  boon  com- 
panions were  busy  picking  pockets. 

t  For  an  explicit  account  of  this  struggle  see  Wharton  and  Stille,  p.  532. 


INSAXITY  AND    CHIME.  201 

lectual  faculties  as  well.  Maudsley  (p.  58)  not  many  years  ago  went  out 
of  his  way  to  clef  end  tlie  rig-hts  of  moral  insanity.  "  It  may  be  witnessed 
even  in  young  children  who,  long  before  they  have  known  what  vice 
meant,  have  evinced  an  entire  absence  of  m<n"al  feeling,  with  the  active 
display  of  all  sorts  of  immoral  tendencies— a  genuine  moral  imljecility 
or  insanity."  But  the  author  is  compelled  to  add  that  "  associated  with 
this  defect  there  is  frcnpiently  more  or  less  intellectual  defi<_'iency,  Imt 
not  always ;  it  sometimes  happens  tliere  is  a  remarkably  acute  intellect 
with  no  trace  of  moral  feeling."  The  "acute  intellects"  are  rare  indeed 
among  moral  imbeciles,  and  such  acuteness  as  there  may  be  is  overshad- 
owed by  huge  defects  in  other  directions. 

Those  who  wish  to  establish  moral  insanity  as  a  special  form  of  men- 
tal derangement  claim  that  the  moral  sense  is  distinctly  hereditary.  But 
this  is  scarcely  conceivable.  The  moral  sense  is  the  highest  faculty  of 
man ;  it  is  not  a  quality  inherent  in  the  brain  of  man,  but  is  in  reality 
a  highly  complicated  concept  resulting  from  the  daily  experiences  and 
teachings  of  parents  and  teachers :  if  such  teachings  have  not  lieen  given 
the  moral  sense  will  be  but  poorly  or  not  at  all  developed ;  if  the  teach- 
ings fall  upon  a  deficient  intellect,  upon  soil  not  fit  to  receive  them,  they 
will  bear  but  little  fruit,  and  the  moral  sense  will  not  be  developed. 
Idiots  and  imbeciles  are  naturally  afflicted  with  moral  insanit}^  and  with 
much  more  in  addition.  Imbeciles  of  minor  degree  may  conceal  their 
intellectual  defects,  but  the  moral  defect  stands  out  prominently ;  such 
imbeciles  lack  the  power  of  absorbing  those  higher  concepts  which  are 
essential  to  the  develojjnieut  of  a  high  moral  sense. 

Meyuert  {Gehirn  n.  Gesittung,  Vienna,  1889)  was  surely  correct  in  his 
opinion  that  the  seat  of  the  moral  sense  must  be  looked  for  in  the  entire 
hemispheres,  in  the  mechanisms  of  association,  the  bearer  of  iutelhgence 
in  general.  The  moral  sense  represents  the  highest  function  of  the  hu- 
man brain,  and  for  that  reason,  on  well-known  principles  of  evolution 
and  dissolution,  it  is  the  last  (the  most  difficult)  to  be  acquired  and  the 
first  to  be  lost  from  disease.  The  loss  of  morality  may  therefore  be  notice- 
able before  intellectual  decadence  has  set  in ;  it  often  oj^ens  up  the  scene, 
but  other  symptoms  will  follow  before  the  entire  sad  drama  is  enacted. 
As  Lloyd  {J.  of  Nerv.  and  Mental  Disease,  1886,  p.  681)  puts  it :  "  The  doc- 
trine of  '  moral  insanity '  proceeds  upon  an  abstraction  .  .  .  that  there  is 
a  moral  '■  faculty '  .  .  .  which  may  remain  undeveloped  in  a  mind  other- 
wise healthj^  and  nia}^  become  diseased  without  at  all  affecting  the  health 
of  the  other  'faculties.'"  Meynert  {Psi/eJiiafr!/,  trans,  by  Sachs)  hits  the 
nail  on  the  head  in  saying,  "It  is  taking  altogether  too  simple  a  view 
of  tilings  to  regard  moi-alit}^  as  one  of  man's  talents,  and  as  a  definite 
psychiatric  property  which  is  present  in  some  persons  and  lacking  in 
others ;  "  and  he  quotes  Weissmann,  who  holds  that  talents  are  the  combi- 
nations of  many  iind  widel^y  different  faculties. 

While  the  present  writer  is  thoroughly  convinced  that  the  defect  in 
morality  is  to  be  ascril)ed  priuuxrily  to  an  intellectual  defect,  it  is  but  fair 
to  say  that  opposing  views  are  held  by  many  prominent  authors :  Lom- 
broso,  Maudsley,  and  Hack-Tuke  will  not  sacrifice  "moral  insanity"  to 
any  theories  regarding  the  true  nature  of  such  defects ;  and  even  Krafft- 
Ebing  recognizes  the  propriety  of  adhering  to  the  clinical  form.* 

*  lu  criminology  moral  insanity  plays  a  verj-  important  part. 


202  ^   SYSTEM  OF  LEGAL  MEDICINE. 

The  justice  of  the  elmieal  claim  cannot  well  be  denied — for  cases  do 
occur  in  which  the  moral  defect  overlaps  all  else — at  least  until  a  careful 
examination  has  established  other  mental  deficiencies.  It  is  positive 
that  few  medical  authorities  of  the  present  day  will  subscribe  to  the 
doctrine  of  moral  insanity  as  fii-st  established  by  Pritchard  {Treatise  on 
Insanity,  1842),  and  adopted  later  on  by  many  French  and  English 
authors.  But  if  the  term  is  to  be  used,  it  will  be  well  to  restrict  it  at  least 
to  those  cases  in  which  the  defective  moral  sense  is  the  most  striking 
symptom.  Some  years  ago  I  saw  at  a  chnic  a  young  man  who  had  been 
arrested  for  an  assaidt  upon  his  mother,  whom  he  had  failed  to  kill.  He 
was  entii-ely  indifferent  to  the  charge  brought  against  him,  and  when 
asked  whether  he  thought  it  was  proper  to  kill  a  mother,  answered,  "  You 
might  as  well  kill  jour  mother  as  any  one  else."  On  fuither  examina- 
tion it  was  found  that  the  man  had  received  no  intellectual  or  moral 
training,  had  received  no  religious  instruction,  had  grown  up  among  the 
most  degenerate  of  mankind,  and  had  never  received  the  most  ordinary 
moral  teachings.  Naturally  the  moral  sense  was  deficient.  The  case 
would  faU  easily  enough  under  Mendel's  ("Moral  Insanity,"  Eulen- 
htrg's  ReaJ-Encydop.,  1888)  definition  of  moral  insanity  as  that  form  of 
insanity  which  is  either  congenital  or  acquired  in  the  earlier  years  of 
life,  and  is  characterized  by  imbecility,  associated  with  a  morbid  tendency 
to  immoral  actions.  Binswanger's  {Yolhnann  Sammlung,  No.  299)  view 
is  unquestionably  the  most  correct :  that  a  number  of  mental  diseases 
may  lead  to  "moral  idiocy." 

A  single  example  will  illustrate  the  condition  of  moral  insanity ;  the 
case  is  reported  by  Krauss  {Friedreich's  Blatter,  vol.  xxxviii.) : 

"  A  girl  twelve  years  old,  daughter  of  a  seamstress,  stole  the  earrings 
of  a  child  three  and  a  half  years  old  to  buy  sweetmeats  with  the  proceeds 
of  the  sale,  and  threw  the*  child  out  of  the  window.  The  child  died  of 
fractured  skuU.  The  murderess  seems  mentally  and  physically  the 
equal  of  children  of  her  age.  The  face  has  a  distinct  canine  expression ; 
she  was  always  unemotional,  lazj'-,  and  would  steal  sweets ;  at  the  age  of 
four  she  would  pierce  the  eyes  of  rabbits,  and  would  rip  open  theu-  bel- 
lies. She  knows  that  it  is  wrong  to  do  certain  things,  but  has  no  ethical 
feeUngs ;  she  felt  no  remorse  over  the  murder  of  the  cliild.  The  prose- 
cuting attorney  inferred  that  she  knew  the  nature  of  her  crime  and  its 
penalty.  The  cornet  sent  her  to  a  reformatory  for  eight  years,  overruling 
the  testimony  of  experts  as  to  her  defective  moral  condition."  This  was 
moral  insanity  if  you  choose,  but  it  included  a  distinct  defect  of  judg- 
ment and  of  all  the  intellectual  functions. 


PARETIC  DEIVIENTIA,  DEIMENTIA  PARALYTICA,  OR  GENERAL  PARESIS  OF  THE 

INSANE. 

Considering  the  unusual  and  increasing  frequency  of  dementia  para- 
lytica, it  leads  less  frequently  to  crimes  than  many  other  forms  of  in- 
sanity. This  is  accounted  for  by  the  rapid  weakening  of  all  the  faculties, 
which  does  not  permit  the  lunatic  to  carry  out  any  well-designed  plan 
of  revenge  or  the  like.  Such  acts  as  he  commits  are  more  apt  to  result 
'from  loss  of  reasoning,  from  carelessness,  or  from  the  exaggerated  notion 
of  his  own  prowess  which  the  paretic  entertains  in  the  earlier  stages  of 


I]:^SANIT¥  AND    CRIME.  203 

the  (lis(^;ise.  He  is  met  with  move  often  in  civil  than  in  criminal  courts. 
Squandering  of  mouey,  neglect  of  wife  and  children,  false  promises  of 
marriage,  lack  of  testiimentary  capacity,  cause  innumerable  suits  and 
complications.  Yet  the  increased  sexual  appetite,  the  feeling  of  inordi- 
nate strength,  maniacal  excitement,  leading  to  deeds  of  violence,  often 
enough  make  the  paretic  a  criminal. 

Crimes  are  perpetrated,  as  a  rule,  during  the  earliest  period  of  the 
disease,  at  a  time  when  the  general  symptoms  VLViiy  be  so  slight  that  even 
experts  may  differ  as  to  the  existence  of  the  disease.  It  is  therefore  of 
special  im2)ortance  that  the  medical  man  and  the  lawyer  understand  the 
symptoms  and  coui-se  of  the  disease,  and,  above  all,  the  signs  of  the  pro- 
di'omal  period. 

The  disease  begins,  as  a  rule,  in  a  very  insinuating  fashion ;  it  attacks 
men  more  frequently  than  women,  setting  in,  as  a  rule,  between  the  ages 
of  thirty-five  and  forty-five  years  ;  exceptionally  it  may  begin  much  earlier. 
I  have  seen  it  begin  at  the  age  of  twenty-one  years,  and  one  author  has 
reported  a  typical  case  in  a  girl  of  sixteen.  In  a  very  large  proportion 
of  cases  syphilitic  infection  has  preceded,  sometimes  by  man}^  years,  in 
other  cases  only  by  a  few  months  or  a  year.  Syphilis  is  the  predisj)OS- 
ing  cause — not,  as  a  rule,  the  direct  exciting  cause.  The  greater  struggle 
for  existence,  the  cares  and  responsibilities  of  business,  worrimeut  with 
overwork — not  overwork  alone — these  are  the  chief  causes  that  help  to 
develop  the  disease.  As  men  are  more  exj)0sed  to  all  these  influences, 
we  can  understand  why  general  paresis  should  be  more  frequent  in  them, 
and  why  it  should  be  more  frequent  among  negroes  now  than  it  was 
while  they  were  in  slavery. 

A  very  slight  change  in  the  character  and  morals  of  a  person,  in  his 
business  methods  and  habits,  may  be  the  first  indication  of  paresis.  The 
father  of  a  family,  always  most  correct  in  his  habits,  takes  to  di-ink, 
forms  low  associations,  is  found  in  houses  of  prostitution,  gambles  for 
high  stakes.  The  merchant  becomes  careless  in  his  accounts,  in  signing 
checks,  in  his  treatment  of  his  surroundings ;  is  unusually  ii'ascible  to- 
ward his  employees,  or  treats  them  with  absurd  consideration.  A  patient 
of  mine,  who  never  bothered  about  the  comfort  of  liis  factory-girls,  or- 
dered ice-cream  and  lemonade  every  afternoon  for  the  girls  in  his  einploy, 
and  insisted  on  their  working  only  a  very  few  hours  each  day.  Such 
signs  may  appear  trivial,  but  a  change  in  a  person's  behavior  without 
sufficient  reason  may  be  sufficient  to  justify  the  physician's  fears.  Before 
long  the  morbid  character  of  the  change  will  become  apparent  enough, 
as  the  disease  is  rapidly  progressive. 

With  the  advance  of  the  disease  two  distinct  sets  of  symptoms  are 
manifested.  These  are  partly  psj^'hic  and  partly  physical  in  nature. 
The  psychic  condition  is  characterized  by  a  progressive  weakening  (de- 
mentia) of  all  the  faculties;  memory  and  judgment  become  seriously 
imi)aired ;  the  paretic  may  be  in  a  melancholy,  hypoclunulriacal  mood, 
or  in  a  condition  of  exaltation  with  delusions  of  grandeur :  he  is  the 
richest  man  in  the  world ;  owns  all  the  shops,  every  railroad  in  the  coun- 
try ;  has  innumerable  mines,  and  is  going  to  build  houses — as  an  unfor- 
tunate architect,  a  patient  of  mine,  claimed — covered  with  gold,  and  con- 
taining diamond,  not  glass,  widows.  The  delusions  are  not  systematized. 
He  says  he  is  rich,  but  does  not  act  the  rich  man.  He  is  king,  but  does 
not  exact  homage  from  his  subordinates.     There  is  a  progressive  deteri- 


204  A   SYSTEM   OF  LEGAL  MEDICIXE. 

oration  of  all  the  faculties  until  a  complete  dementia  is  developed,  and 
the  man,  once  intelligent,  is  nothing-  more  than  an  animal  organism 
animal-hke  in  his  appetites,  and  contented  if  these  are  satisfied. 

The  jDhysical  signs  of  general  paresis  are  inequahty  of  the  pupils 
failure  of  the  pupils  to  react  to  hght — sometimes  both  to  light  and  dur 
ing  accommodation ;  tremor  of  the  tongue  and  of  the  facial  muscles 
tremor  of  the  hands ;  awkwardness  in  all  movements ;  great  difficulty  in 
buttoning  clothes,  in  writing,  in  whistling,  in  plajdng  of  instruments. 
Speech  becomes  tremulous,  hesitating,  and  defective ;  words  are  slurred 
and  run  into  each  other ;  sentences  are  begun  and  not  finished ;  in  re- 
peating sentences  words  are  omitted ;  the  legs  grow  weak,  and  locomo- 
tion may  become  difficult  or  altogether  impossible.  Both  the  mental 
and  physical  symptoms  are  progressive,  and  often  in  course  of  two  or 
three  years,  during  which  time  epileptic  and  aj)oplectic  attacks  may  occur, 
death  ends  the  sad  career. 

The  physical  sjanptoms  often  j)recede  the  mental,  and  for  this  reason 
the  greatest  importance  must  be  attached  to  them ;  and  during  the  earlier 
periods,  too,  excesses  and  crimes  are  apt  to  be  committed  in  the  feeling 
of  exaltation  or  during  a  maniacal  attack. 

The  silliness  of  the  criminal  act,  the  failure  to  conceal  the  deed,  often 
point  to  general  paresis.  Magnan  *  refers  to  a  paretic  who  asked  two 
pohcemen  to  help  him  remove  a  full  barrel  of  wine  lying  in  front  of 
a  wine-dealer's  shop.  If  caught  in  the  act  and  caUed  to  account,  paretics 
either  deny  the  theft  or  give  some  silly  excuse,  showing  that  they  do 
not  appreciate  the  gra^dty  of  the  situation.  They  are  apt  to  pick  up 
an;si:hing  they  can  lay  hands  on,  and  in  asylums  either  take  things  delib- 
erately from  other  patients,  pick  up  paper  and  cigar-stumps,  or  pocket 
every  sort  of  rubbish.  At  times  these  patients  are  tricky.  A  patient  of 
Mendel's  gave  a  "box  of  cigars"  in  pajnnent  of  a  debt ;  instead  of  cigars 
the  box  contained  potato-23eehngs,  wliich  he  claimed  got  into  the  box  in 
some  way  unknown  to  him.  Exposure  of  the  person  is  a  very  frequent 
occurrence ;  masturbation  in  public,  particularly  in  the  presence  of 
women  and  children,  is  common  enough.  Westphal  [Arch.  f.  Fsijch., 
vol.  vii.,  p.  622)  mentions  a  paretic  forty  years  of  age  who  directed  the 
attention  of  girls  between  the  ages  of  eleven  and  thirteen  years  to  his 
penis,  and  used  obscene  language  in  doing  so.  A  patient  of  mine  invited 
the  servant-girl  into  his  bedroom  at  night,  and  attempted  sexual  inter- 
course with  her  in  the  presence  of  his  mfe.  Not  a  few  have  invited 
j)rostitutes  to  their  own  homes  and  introduced  them  into  their  families. 
Capital  crunes  are  not  frequent;  if  committed,  the  motives  are  either 
wanting  altogether  or  extremely  silly.  A  laborer  aged  fortj^-six  years 
murdered  his  wife  liecause  he  wished  to  enlarge  his  business  and  his  wife 
was  not  his  ecpial ;  he  then  Trashed  to  take  his  own  life.  After  the  mur- 
der he  tells  Ids  neighbors  that  his  wife  died.  He  denied  the  murder  at 
fii'st,  but  later  on  became  entirely  indifferent. 

These  eases  are  sufficient  to  illustrate  the  importance  of  diagnosticat- 
ing the  early  stages  of  general  paresis. 

*  Full  literatm-e  to  be  found  in  Mendel's  Monograpli. 


IXSJXITY  AM)    CHIME.  205 

TOXIC  INSANITIES. 

Alcohol,  morphine,  and  cocaine  are  the  three  toxic  substances  which, 
if  taken  in  excess,  produce  serious  disturl)ances  of  the  central  nervous 
system.  Mental  derang-ement  is  a  common  effect  of  the  long-continued 
use  of  these  poisons,  and  crime  is  its  unfoi-tunate  accompaniment. 

Alcoholism. — The  evil  intiuence  of  alcoholism  is  not  sufflcientl}'  rec- 
ognized by  the  laity  or  tlie  medical  frateruit}'.  Social  custom  has,  in 
most  countries,  sanctioned  the  free  use  of  alcohol ;  the  occasional  drunk- 
ard is  despised  everyAvhere,  hut  the  man  who  poisons  his  system  with 
alcohol  day  by  day,  without  at  any  time  putting  his  intoxication  in  e\d- 
■denee,  is  not  censured  for  the  habit,  although  he  is  even  more  certain 
than  the  occasional  drunkard  to  develop  the  serious  form  of  chronic 
alcoholism. 

In  this  country  whiskey  and  rum  are  the  deadly  poisons,  l^ut  wine  and 
beer  have  theii'  victims  as  well.  A  reaction,  and  a  healthy  one  at  that, 
is  uncpiestionably  setting  in ;  even  in  Germany  the  caoI  effects  of  chronic 
alcoholism  are  now  recognized  and  publicly  discussed.  Striimpell  has 
set  forth  the  degenerating  influences  of  alcohol  upon  the  German  people, 
and  another  physician  has  asked  the  medical  fratei'iiity  in  Germany  to 
set  the  example  of  absolute  abstinence  in  order  that  others  may  take 
heart  and  free  themselves  from  this  overpowering  \dce. 

This  is  not  the  proper  place  to  decide  whether  total  abstinence  or 
moderate  use  of  alcoholic  liquors  is  in  order ;  we  must,  however,  take 
into  account  the  relation  of  crime  to  chronic  alcoholism. 

In  Germany,  it  is  claimed,  fully  fifty  percent,  of  all  crimes  are  com- 
mitted under  the  influence  of  alcoholic  excesses ;  in  England  and  America 
the  percentage  is  no  doul^t  ecpially  high.  As  every  person  is  in  a  meas- 
ure responsible  for  the  vice  to  which  he  has  fallen  a  victim,  the  question 
arises  whether  he  shall  be  declared  responsible  for  deeds  committed  as  a 
result  of  such  vice.  The  "vice  -is  so  common  among  the  sane  criminal 
classes  that  to  accept  alcoholic  intoxication  as  an  excuse  for  crime  would 
be  placing  a  premium  upon  his  misdeeds.  Alcoholism  can  be  an  ex- 
cuse for  crime  only  if  it  has  led  to  the  development  of  an  insanity,  of  a 
distinct  form  of  mental  derangement ;  and  if  so  the  alcoholist  is  as  little 
responsi»ble  for  his  deeds  as  the  paretic  criminal  is  whose  paresis  is  the 
residt  of  sj^j^hilis.  On  the  whole,  the  coiirts  in  various  States  of  the  Union 
have  taken  this  view  of  the  subject :  that  intoxication  is  no  excuse  for 
crime,  but  that  insanity  resulting  from  long-continued  drunkenness  is 
an  excuse  for  crime.  (See  Lawson,  chap,  iii.)  The  medical  expert  and 
the  jurist  should  therefore  have  a  clear  understanding  of  the  symptoms 
of  alcoholic  insanity. 

The  first  and  most  prominent  result  of  chronic  alcohohc  poisoning- 
is  a  progressively  increasing  weakness  of  all  the  psychic  functions,  a  de- 
generation of  the  moral  and  intellectual  faculties.  The  chronic  drunk- 
ard becomes  neglectful  of  his  family  and  his  business.  Society  despises 
him,  and  he  despises  all  those  who  interfere  with  him ;  he  may  lead  his 
family  to  starvation,  but  he  cares  little  as  long  as  his  morbid  cra\dng 
may  be  satisfied ;  he  becomes  irritable  and  brutal,  not  only  when  under 
the  immediate  influence  of  the  drink,  but  particularly  diu'ing  a  period 
(however  short)  of  abstinence.  In  the  early  morning  hours  he  is  most 
apt  to  be  irritable,  ugly,  and  dangerous  to  his  surroundings.    He  endeav- 


206  ^   SYSTEM  OF  LEGAL  MEDICINE. 

ors  to  rid  himself  of  tlie  liabit,  but  does  not  possess  sufficient  energy^ 
and  gives  np  the  fight  in  despair.  As  the  disease  or  the  habit  takes  a 
firmer  hold  he  becomes  stupid,  weak-minded,  obtuse ;  his  memory  for- 
sakes him,  and  he  soon  becomes  thoroughly  helpless.  His  sleep  is  restless,. 
and  both  day  and  night  he  is  troubled  by  all  sorts  of  disagreeable  visual 
hallucinations.  He  becomes  suspicious  of  his  surroundings,  and  devel- 
ops complete  delusions  of  persecution.  The  delusion  of  marital  infidelity 
is  so  common  as  to  be  well-nigh  pathognomonic  of  this  condition. 

There  are  physical  symptoms,  also,  which  are  characteristic  of  the  alco- 
holic state :  partesthesia  and  formication  in  the  extremities ;  tremor  and 
weakness  of  hands  and  legs.  Tremor  of  the  tongue  and  of  the  face- 
muscles  appears  quite  early  in  the  disease  ;  also  fibrillary  twitchings  of  the 
tongue  and  disturbances  of  speech.  Among  the  later  symptoms  are  loss 
of  pupillary  reflexes,  loss  of  vision,  and  even  epileptic  seizures. 

The  crimes  of  the  chronic  drunkard  are  either  the  result  of  his  degen- 
erated morals  and  of  his  general  intellectual  weakening,  or  the  result  of 
uncontrollable  passions  and  emotions.  In  some  instances  the  delusions 
of  infidelity  and  the  delusions  of  persecution  may  lead  to  acts  of  revenge. 
Such  delusions  are  occasionally  developed  after  an  acute  intoxication. 
A  patient  of  mine — a  man  of  fine  intellectual  qualities — celebrated  the 
departure  of  a  friend  for  Europe  by  an  '' old-fashioned  spree,"  as  he 
called  it.  On  his  way  to  this  city  from  Hoboken  he  claimed  he  fell  in 
with  a  woman  who  had  a  child  with  her.  This  child  he  had  lim-led  inta 
a  stove  in  order  that  he  might  be  alone  with  the  woman,  and  he  was  cer- 
tain that  the  pohce  were  after  him  (as  a  matter  of  fact  he  was  brought 
home  safely  by  an  acquaintance).  For  a  long  time  after  this  occiu*- 
rence  he  was  certain  of  the  reality  of  his  belief,  for  people  on  the  elevated 
railway  pointed  at  him  with  scorn  and  made  all  sorts  of  remarks  about 
him  :  "  There  he  goes — the  murderer,"  "  He  is  pretending  to  be  a  gentle- 
man," etc.  It  was  very  nearly  a  year  before  these  delusions  entirely  dis- 
appeared. Such  delusions  as  these  may  lead  either  to  suicide  or  homi- 
cide (revenge  for  persecution). 

Krafft-Ebing  (p.  188)  records  a  very  typical  case,  which  I  summarize 
as  follows :  A  locksmith  thirty-six  years  of  age ;  married  nine  years  ;  two- 
children  ;  addicted  to  drink  from  early  youth ;  suspected  his  wife  of  in- 
fidelity ;  neglected  his  work ;  was  irritable  and  brutal  toward  'his  wife^ 
maltreated  her,  and  on  one  occasion  almost  killed  her  in  a  fit  of  passion  ; 
was  sent  to  prison,  but  was  not  convicted,  as  he  was  declared  insane. 
Three  years  later  threatened  his  wife  again,  and  was  brought  before 
court ;  accused  his  wife  of  being  a  Xanthippe  (particularly  on  Sundays^ 
when  he  was  drunk),  and  of  infidelity,  which  he  was  certain  of  because 
she  was  away  too  long  on  errands,  flirted  with  men,  etc. ;  but  his  wife  was 
a  decrepit,  exhausted,  but  respectable  woman.  His  wife  removed  him  from 
the  asylum ;  in  a  fit  of  temper  a  few  weeks  later  he  smashed  her  skull 
and  endeavored  to  kill  himself  by  ripping  open  his  own  belly ;  he  showed 
no  remorse  for  his  deed,  and  excused  himself  on  the  plea  of  his  wife's 
(supposed)  infidelity  and  her  quarrelsome  disposition. 

During  the  period  of  abstinence  crimes  may  be  committed,  as  illus- 
trated by  the  following  case  : 

Drew,  the  captain  of  the  ship,  had  murdered  the  second  mate.  "  It 
appeared  that  for  a  considerable  time  before  the  fatal  act  Drew  had  been 
in  .  .  .  almost  continual  drunkenness;  that  about  five  days  before  it 


IXSJXITV  AND  rniME.  207 

t<)(»k  place  he  ordered  all  the  li(in()r  on  hoard  to  V)e  thrown  overboard, 
which  was  accordingly  done  ;  .  .  .  soon  afterward  became  restless ;  .  .  . 
expressed  his  fears  that  the  crew  intended  to  mnrder  him,  and  com- 
])lained  of  persons  who  were  unseen  .  .  .  ur<iin<;-  him  to  kill  Clark.  The 
night  before  the  act  he  was  more  restless,  seemed  to  be  in  great  fear,  and 
whenever  he  hiy  down  there  were  persons  threatening  to  kill  him  if  he 
did  not  kill  the  mate."  (Lawson,  p.  GOl.)  Judge  Story  recognized  the 
insanity  in  the  case,  and  declared  the  act  not  to  be  that  of  a  reasonable 
being. 

Criminal  acts  are  also  committed  during  the  condition  of  deUriuin 
tremens,  a  condition  of  exhaustion  with  maniacal  excitement  in  which 
the  person  is  totally  unconscious  and  irresponsible  for  his  actions.  We 
need  not  give  illustrative  cases  of  this  condition,  nor  of  the  condition  of 
alcoholic  epilepsy,  which  occurs  in  almost  ten  percent,  of  all  chronic  alco- 
holic cases.  Lilve  other  epileptic  states,  this  one  is  attended  by  impulses 
of  the  most  violent  character,  in  which  the  alcoholist  may  kill  wife  or 
brother  without  being  aware  of  the  character  of  the  deed.  Crothers,  of 
Hartford,  has  called  special  attention  to  the  conditions  of  trance  andsom- 
naml>ulism  in  chronic  alcoholists. 

Morphine  Habit. — Morphine  is  not  as  powerful  a  poison  as  alcohol, 
and,  fortunately,  the  use  of  it  is  not  as  widespread  as  that  of  alcoholic 
stimulants.  But  it  has  fully  as  strong  a  hold  upon  its  victims,  and  leads 
even  inore  rapidly  than  alcohol  does  to  a  degeneration  of  the  entire  nerv- 
ous S3'steni  and  to  mental  imbecility.  The  habit  is  engendered  in  many 
different  ways.  Many  fall  into  the  habit  after  an  acute  illness  in  which 
opium  or  morphine  was  given  for  the  relief  of  pain.  Having  once  tasted 
the  sweets  of  the  opium  dream,  they  resort  to  it  on  the  occasion  of  the 
least  pain,  and  the  very  craving  establishes  the  2)ain.  Druggists,  phy- 
sicians, physicians'  wives,  and  nurses  fall  victims  most  easily  to  this 
scourge,  because  they  can  easily  get  as  much  of  the  drug  as  they  A\ish. 
The  system  becomes  accustomed  rapidly  to  the  di*ug,  and  huge  quantities 
can  be  taken  without  immediate  danger  to  life,  though  many  a  morpliine 
hahifue  has  met  his  death  by  an  accidental  overdose. 

The  condition  produced  by  excessive  use  of  morphine  varies  in  differ- 
ent individuals.  As  a  rule  there  is  at  first  great  u-ritability  of  temper, 
excessive  restlessness  (allayed  for  a  time  by  each  fresh  dose),  lack  of 
energy  and  application  to  work,  a  distinct  loss  of  memory,  which  may 
ultimately  lead  to  complete  apathy  and  imbecility.  Early  in  the  career 
of  the  morphine  fiend  a  general  depra\dty  is  noticeable :  he  shows  a  dis- 
regard for  truthfubiess,  and  will  resort  to  any  subterfuge,  even  to  steal- 
ing, to  get  his  drug.  No  trick  is  too  despical>le  for  the  person  who  craves 
nu^rphine  and  cannot  get  it.  Even  in  hospitals  it  is  a  common  practice 
to  bribe  attendants — to  make  the  most  extravagant  promises  if  they  will 
secm-e  the  deadly  poison  for  them  ;  but  when  the  physician  questions  the 
patient  he  is  alisolutely  ignorant  of  any  attempt  at  briliery. 

While  every  person  may  be  held  responsible  for  the  beginning  of  the 
hal)it,  the  continuance  of  the  habit  removes  such  responsibility.  The 
misdeeds  of  a  morphine  liahitue  can,  however,  be  attributed  to  the  habit 
only  if  he  exhil)it  distinct  symptoms  of  morphine  insanity.  He  must 
present  some  siich  condition  as  was  referred  to  above,  and  a  few  of  the 
])hysical  symptoms;  among  these  the  most  im])ortaut  are  tr<'mor,  ataxia, 
myosis,  profuse  sweating  on  the  least  exertion,  nausea,  and  disgust  for 


208  ^   SYSTEM  OF  LEGAL  MEDICINE. 

all  animal  food.  Furuncles  in  tlie  skin  and  abscesses  will  give  some 
idea  of  the  frequency  of  the  practice. 

The  worst  crimes  are  not  often  the  result  of  the  morphine  habit,  but 
petty  crimes  are  all  the  more  frequent.  Phj'sicians  who  use  morphine 
on  their  own  persons  in  large  quantities  become  extremely  careless  in 
prescribing  this  and  other  drugs  for  their  patients.  No  one  who  uses 
morphine  habitually  can  be  considered  to  be  in  a  normal  mental  state, 
for  his  condition  varies  with  the  quantity  of  morphine  he  has  in  his 
system.  As  soon  as  the  period  of  abstinence  is  reached  he  is  possessed 
by  a  spirit  of  restlessness  which  makes  him  thoroughly  irresponsible 
and  incapable  of  sober  reasoning. 

A  common  offense  among  morphine  Jiabitnes  is  the  forging  of  pre- 
scrij)tions  calling  for  morphine,  or  the  theft  of  morphine  from  the  office 
of  physicians  or  from  the  shelves  of  the  druggist.  Erlenmeyer  (p.  214) 
reports  the  case  of  a  young  woman  who  forged  the  prescription  of  a 
physician  calling  for  1.2  niorjDh.,  which  the  patient  changed  to  6.2  ! 
adding  the  exclamation-mark  which  the  German  law  demands  in  case  of 
large  doses ;  the  patient  was  sent  to  prison  for  ten  days. 

Like  alcohol,  morphine  leads  to  neglect  of  business,  to  loss  of  social 
position,  and  to  poverty.  In  this  condition  a  person  who  Avas  once  en- 
tirely honest  will  resort  to  petty  thefts,  perha,ps  to  help  his  family, 
but  more  often  to  secure  money  enough  to  buy  morphine  for  himself. 
The  general  depravity  of  morals  which  the  morphine  habit  entails  is  the 
saddest  symptom  of  all.  Not  long  ago  I  treated  a  once  well-to-do  mer- 
chant who  had  brought  himself  and  his  family  to  the  verge  of  ruin  by 
tlie  use  of  morphine.  He  endeavored  to  free  himself  from  the  habit, 
but  had  not  the  moral  courage  to  do  so.  In  former  days  too  proud  to 
accept  a  favor  of  any  one,  he  allowed  his  relatives  now  to  support  him 
and  his  family. 

The  mere  use  of  morphine  is  not  a  sufficient  excuse  for  crime  unless 
the  distinct  symptoms  of  morphine  psychosis  are  present.  Unless  this 
principle  is  adhered  to  criminals  might  find  it  to  their  advantage  to  be- 
come addicted  to  the  drug.  In  the  following  case  this  difficulty  was  rec- 
ognized, and  the  prisoner  was  declared  guilty. 

The  prisoner  was  twenty-nine  years  of  age,  an  illegitimate  child ; 
father  unknown ;  history  of  insanity  in  mother's  family.  With  exception 
of  syphilis  the  prisoner  had  no  illness ;  did  satisfactory  work  as  hospital 
nurse  during  a  period  of  fourteen  months ;  in  this  time  practiced  daily 
hypodermic  injections  of  morphine,  began  to  sleep  poorly,  was  depressed 
(love-affair  in  addition),  and  was  not  quieted  by  morphine.  September 
12, 1887,  he  was  severely  rebuked  for  his  relations  to  a  female  nurse,  and 
discovered  that  one  A.  liad  told  on  him.  He  desired  to  avenge  himself 
at  once,  but  took  morphine  injection  instead ;  the  very  next  morning,  how- 
ever, he  stal^bed  A.  while  in  bed  and  fired  four  bullets  into  his  own  body. 
Immediately  after  the  act  he  appeared  normal,  and  exhibited  no  absti- 
nence symptoms  on  the  absolute  Avithdrawal  of  the  drug — no  physical 
anomalies,  and  no  stigmata  of  degeneration.  The  experts  declared  that 
morphine  lial)ltues  must  be  divided  into  two  categories :  in  the  one  class 
we  must  place  individuals  with  tainted  ancestry  and  a  tendency  to  neu- 
roses, who  are  impelled  to  the  use  of  various  poisons,  such  as  morphine, 
alcohol,  or  cocaine ;  the  other  class  is  made  up  of  individuals  who  dis- 
cover the  charms  of  morphine  accidentally  during  a  painful  illness  and 


ixsjyiTv  JXD  CHIME.  209 

then  become  addicted  to  it.  In  this  special  ease  the  experts  declared 
that  the  prisoner  exhibited  only  slight  symptoms  of  the  morphine  habit, 
that  there  was  no  trouble  on  withdrawing  the  di-ug,  and  that  the  use 
of  morphine  in  his  case  did  not  in  anywise  affect  the  question  of  respon- 
sibility. He  was  found  sane,  and  was  condemned  to  five  years  at  hard 
labor.  (Contagne  et  Bernard,  Arcliiv.  de  VAntliropoJ.  Criniinelles,  vol.  v., 
No.  25.) 

The  cocaine  habit  is  the  most  recent  affliction  of  man.  It  is  en- 
gendered accidentally  in  the  majority  of  cases.  I  have  known  it  to  re- 
sult from  the  application  of  the  drag  to  the  nostrils,  the  patient  continu- 
ing in  private  what  the  phj'sician  jiracticed  upon  him  in  his  office  for  the 
purpose  of  treating  the  membranes  of  the  nose.  The  sensation  of  apply- 
ing it  is  distinctly  disagreeable,  but  the  habit  is  easily  developed  when 
once  begun.  Those  who  have  been  addicted  to  morphine  or  alcohol,  and 
are  trying  to  abstain  from  either,  often  resort  to  cocaine  as  a  lesser  evil. 
And  such,  on  the  whole,  it  is ;  but  if  added  to  the  horrors  of  the  mor- 
phine or  alcohol  habit,  it  makes  a  sad  wreck  of  the  individual. 

The  general  symptoms  are  very  much  the  same  as  those  of  morpliine 
insanity :  horrible  visual  and  auditory  hallucinations,  delirium  of  perse- 
cution, visions  of  small  animals.  Intense  restlessness  and  sleeplessness, 
nausea,  and  anorexia  are  the  chief  sjTuptoms.  In  one  case  of  mine  a 
patient  who  had  passed  with  the  usual  success  through  a  Keeley  cure 
was  alternately  addicted  to  alcohol  and  cocaine ;  he  was  unfitted  for 
business,  was  constantly  and  natiu^ally  at  loggerheads  with  his  family, 
neglected  wife  and  children,  and  was  a  burden  to  his  home  until  he  con- 
quered l)oth  habits,  at  least  temporarily.  It  was  my  sad  duty  some  years 
ago  to  treat  a  brother  physician  who  had  rid  himself  of  the  morphine 
habit  and  fell  victim  to  cocaine,  then  lapsed  into  morphine  again  ;  he  con- 
tinued both  drugs,  was  utterty  unable  to  attend  to  his  practice,  became 
poverty-stricken,  and  finally  committed  suicide. 

The  drug  does  not  fascinate  the  indi^-idual  as  morphine  does,  nor  has 
it,  to  the  writer's  knowledge,  led  to  any  serious  crime  as  yet,  except  that 
of  neglecting  one's  family  and  of  leading  to  suicide ;  but  let  it  be  con- 
tinued, and  the  danger  of  criminal  acts  on  the  part  of  the  cocaine  habitue 
becomes  probable  enough. 

HYSTERICAL  EsSAXITY. 

In  my  lectures  to  physicians  on  nervous  diseases,  I  am  in  the  habit  of 
saj'iug  that  hysteria  in  this  country  is  a  rare  form  of  disease.  Startling 
as  this  statement  may  seem,  it  is  absolutely  true  if  we  restrict  the  term  to 
the  graver  form  of  the  disease,  and  do  not  make  the  diagnosis  of  hysteria 
for  the  same  conditions  to  which,  if  they  occur  in  man,  we  apply  the 
term  "  nervous."  Hysteria  leading  to  crime  is  still  rarer  in  this  country, 
but  is  becoming  more  and  more  frequent  among  the  Russian,  French, 
and  Italian  elements  of  our  mixed  popidation.  The  aggravated  forms 
of  hysteria  are  most  common  in  France,  and  have  been  studied  most 
carefully  by  French  medical  writers,  alcove  all  by  Charcot  and  his  fol- 
lowers.    They  have  created  the  modern  concei)tion  of  hysteria. 

Hysteria  proper,  la  (ivaudc  hijsterie,  the  condition  M-ith  which  we  are 
most  concerned  in  this  article,  is  characterized  hx  an  unusual  develop- 
ment of  the  emotional  faculties.     The  slightest  cause  is  sufficient  to 


210  J-   SYSTEM   OF  LEGAL  2IEDLC1XE. 

produce  great  emotional  distm*bauee ;  tliere  is  a  continuous  alternation 
between  pleasurable  and  depressed  moods,  the  latter  preponderating. 
Hj^oehondriacal  tendencies  are  common.  •  Every  sensation,  however 
slight,  is  tiu'ned  to  account ;  danger  and  ill  health  are  always  impending. 
By  close  observation  of  their  o'^vn  physical  condition,  patients  become 
egotistical  and  selfish  to  an  unusual  degree.  Every  one  is  made  to  dance 
attendance  U23on  them,  and  from  theii'  own  selfish  point  of  \ievr  they 
are  the  pivot  about  which  everything  tiums.  They  are  ever  mindful  of 
themselves  and  culpably  indifferent  toward  others.  If  the  family  grow^ 
callous  toward  their  sufferings,  they  exaggerate  these,  and  will  simulate 
all  sorts  of  conditions ;  wiU  run  any  and  every  risk  (tui'U  on  the  gas,. 
swallow  glass,  needles),  will  do  anything  to  attract  attention ;  wiU  de- 
liberately commit  suicide  for  the  sake  of  a  moment's  notoriety,  in  which 
they  are  often  aided  by  oui*  sensational  press.  If  they  fail  in  such 
efforts,  hysterical  indi^s-iduals  (men  as  well  as  women)  become  revengeful, 
and  if  the  excitement  increases  (in  women  at  the  time  of  menstruation 
more  particularly),  deliria  and  delusions  of  persecution  may  be  developed. 
The  sexual  sphere  is  frequently  involved,  and  under  the  influence  of 
erotic  delusions  respectable  Avomen  may  prostitute  themselves  or  imag- 
ine themselves  the  \dctims  of  man's  sexual  passion.  False  accusations 
and  denunciations  are  the  accompaniment  of  this  condition.  Mysterious 
cases  of  rape  that  have  baffled  the  police  have  been  explained  as  the  re- 
sult of  erotic  delusions  on  an  hysterical  basis.  In  the  condition  of  ex- 
haustion associated  with  severe  hysteria,  morbid  impulses  arise  wliich 
may  lead  to  offenses  against  the  law.  Hysterical  women,  in  their  ego- 
tism, learn  to  despise  their  offspring ;  one  such  mother  told  me  that  she- 
hated  her  child,  and  could  kill  it  for  the  pain  it  gave  her  during  labor. 

The  responsibihty  of  an  hysterical  indiAddual  will  have  to  be  deter- 
miined  in  each  individual  case  ;  to  say  that  a  j)erson  is  hysterical  is  surely 
no  sufficient  excuse  for  crime.  In  every  case  the  e^ddence  of  severe  hys- 
teria should  be  requii'ed.  This  can  be  accepted  only  if  the  person  has 
been  subject  to  severe  hysterical  manifestations  for  a  long  period  of  time. 
Chief  among  these  are  :  unusually  A^olent  and  sudden  changes  of  moods  ; 
hysterical  fits  and  hysterical  trance  conditions  i^rovoked  by  pressure 
upon  hysterogenic  zoiies.  And  in  addition  there  are  a  few  physical  signs 
of  importance :  marked  vasomotor  distui'bances,  anaesthesia  of  one  half 
of  the  body,  with  distinct  involvement  of  all  the  special  senses  in  that 
half,  or  patches  of  anaesthesia  ii'regularly  distributed  over  a  large  portion 
of  the  body.  These  objective  SAmiptoms  will  prove  to  be  of  great  value 
in  a  given  case.  They  will  help  us  to  differentiate  between  a  mere  "  hys- 
terical "  indi\ddual  and  one  suffering  from  hysteria  major. 

Hysteria  of  a  grave  order,  hereditary  hysteria  in  particular,  is  the 
mark  of  a  general  psychic  degeneration,  and  as  such  is  often  associated 
with  more  serious  mental  disturbance.  The  following  examples  will 
suffice  to  illustrate  the  forensic  importance  of  hysterical  insanity : 

An  unmarried  woman  thii'ty-eight  years  of  age  accused  her  father 
that  he  allowed  another  person  to  enter  a  room  occupied  by  herseK  and 
sister,  and  that  this  person  raped  both  of  them ;  "  for  two  years  she  has^ 
been  pregnant  by  this  man."  She  was  not  allowed  to  bring  suit,  so  she 
armed  herself  and  meant  to  waylay  the  offender.  She  was  sent  to  an 
asylum,  where  she  improved.  On  her  disuiissal  she  met  a  lawA'er,  who 
thought  her  sane  and  began  suit  against  the  father  and  the  dii'ector  of 


IXSJXITV  AND    CHIME.  211 

the  asj'luni  for  illegal  detentiou ;  but  her  insanity  was  recognized.  (See 
also  Morel,  p.  087.) 

From  Iluinmoiid  I  take  the  following  case:  "In  1873,  says  M.  Hu- 
-chard,  Mile,  de  JM.,  aged  eighteen  years,  accused  the  vicar  of  the  parish  of 
liaving  committed  a  rape  upon  her.  She  stated  that  on  such  a  day  and 
at  such  an  hour,  while  she  was  saying  her  prayers  in  church,  the  vicar, 
after  having  shut  all  the  doors,  approached  her  and  requested  her  to  go 
with  him  into  the  sacristy.  There  he  had  made,  she  declared,  indecent 
proposals  to  lier,  and,  as  she  repelled  him  with  indignation,  he  had  pointed 
a  dagger  at  her  heart.  She  hnd  fainted,  and  when  she  recovered  her 
senses  she  discovered  that  she  had  ])een  violated.  During  the  trial  of 
the  accused  priest  the  medical  experts  questioned  her  in  regard  to  the 
moihis  f((cie)idi,  and  as  she  answered  by  giving  childish  details,  she  was 
submitted  to  physical  examination,  with  the  result  of  ascertaining  that 
she  was  a  virgin,  and  that  there  were  no  traces  of  violence." 

"  Tardieu  refers  to  a  recent  case,  that  of  a  young  girl,  an  inmate  of  a 
convent  in  Gascony,  wlio  persuaded  her  father  that  she  had  been  made 
the  victim  of  all  kinds  of  tortures  and  unheard-of  outrages.  He,  believ- 
ing what  she  said,  went  before  the  authorities  and  denounced  the  alleged 
perpetrators.  Finding,  however,  that  she  had  deceived  him,  not  a  word 
•of  her  story  being  true,  he  took  his  hfe  from  chagrin  and  mortification." 

To  the  above  might  be  added  another  case,  also  cited  by  Hammond, 
in  wliieh  the  termination  was  sad  enough : 

'•  The  Marquise  de  Prie,  mistress  of  the  Duke  de  Bom-bon,  was  exiled 
from  court,  and,  of  course,  indifference  and  neglect  followed  her  in  her 
retreat.  She,  however,  resolved  to  regain,  by  a  coup  de  theatre^  the  favor 
she  had  lost.  She  announced  that  on  a  certain  da}'  of  the  month,  and 
at  a  certain  hour,  she  would  kUl  herself.  Ev'ery  one  was  amazed  at  the 
declaration  that  one  so  j'onng,  beautiful,  and  attached  to  life  contem- 
plated suicide,  and  the  news  was  received  with  derision.  During  the  few 
days  intervening,  the  marquise  gave  several  fetes,  at  which  she  danced, 
played,  and  amused  herself  as  in  the  days  of  her  highest  favor.  No  one 
had  ever  seen  her  gayer,  more  spirited,  more  adorable.  The  hour  arrived. 
She  called  the  new  lover  she  had  chosen  to  her  side,  and  again  announced 
her  detei'mination.  The  communication  was  received  by  him  with  a 
smile  of  incredulity.  Believing  it  to  be  one  of  those  mystifications  to 
which  she  was  accustomed,  and  that  she  was  acting  a  part,  he  himiored 
her  so  far  as  to  give  her,  with  his  own  hand,  the  draft  she  had  pre- 
pared. It  was  in  reality  poison,  and  she  died  before  assistance  could  be 
given." 

NEURASTHENIA. 

Neurasthenia  is  so  common  a  disorder  among  men  and  women  of  oiu* 
busy  world  that  it  has  become  a  well-recognized  form  of  disorder  even 
among  the  laity,  under  the  terms  of  nervous  exhaustion,  nervous  prostra- 
tion, and  the  like.  It  would  have  little  forensic  importance  were  it  not 
for  the  fact  that  it  is  frequently  the  first  sign  of  an  inherited  taint,  and 
that  it  represents  at  times  the  first  stages  of  more  serious  mental  disturb- 
ances, such  as  hypochondriasis,  paranoia,  and  even  dementia.  In  neuras- 
thenia, moreover,  there  are  periods  of  excitehient  in  which  the  individual 
is  not  fully  responsible,  and,  above  all,  morbid  conceptions  and  morbid 


212  ^  systi:m  of  legal  medicine. 

impulses  are  frequent.  These  have  been  fully  described  in  the  intro- 
ductory pages  of  this  article.  In  former  days,  and  in  mam'  countries 
to  this  day,  the  law  did  not  recognize  such  conditions.  In  the  majority 
of  instances  the  individual  is  able  to  resist  such  impulses,  but  every  now 
and  then  criminal  acts  i-esnlt  directly  from  such  impulses,  or  the  contin- 
uance of  such  morbid  fears  and  impulses  leads  to  a  coofusioual  condi- 
tion in  which  the  sufferer  becomes  wholly  irresponsible.  Special  cases 
need  not  be  cited,  as  the  commission  of  crime  is,  after  all,  rather  rare, 
and  neurasthenia  should  be  accepted  as  an  excuse  for  crime  only  if  de- 
cided mental  changes  can  be  proved  to  have  existed. 


HYPNOTISM. 

The  discussions  of  hypnotism  in  the  secular  press  are  in  inverse  pro- 
portion to  the  importance  attached  to  it  by  medical  men  the  woi-ld  over. 
Even  in  France,  where  the  schools  of  Charcot  in  Paris  and  of  Bernheim 
in  Nancy  have  done  so  much  to  popularize  the  subject,  the  medical  men 
as  a  bod}^  have  not  failed  to  recognize  the  limitations  of  the  subject.  For 
the  present  hypnotism  is  of  greater  theoretical  than  practical  importance 
both  from  a  medical  and  a  forensic  point  of  view.  Charcot,  Richer,  and 
their  followers  regai'd  hypnotism  as  a  condition  similar  to  grand  hysteria^ 
whereas  the  followers  of  Bernheim  hold  that  it  is  a  condition  produced 
by  mere  suggestion,  and  that  this  condition  can  be  excited  in  non-hys- 
terical as  well  as  in  hysterical  suljjeets.  The  present  Avriter  believes  that 
all  "  impressionable  "  individuals  can  be  hypnotized. 

The  novelists  have  made  much  of  these  phenomena  of  hypnotism, 
both  from  an  intrinsic  psychologic  interest,  and  because  it  makes  theii* 
task  very  much  easier.  It  is  fascinating,  I  am  certain,  to  be  able  to 
change  the  characteristics  of  one's  hero  at  will,  to  subject  him  to  all 
sorts  of  occult  influences,  without  being  called  upon  in  the  good  old-fash- 
ioned way  to  explain  minutely  how  such  changes  were  brought  about. 
"Hypnotic  influence"  is  a  convenient  subterfuge.  In  novels  this  influ- 
ence is  generally  exercised  for  evil,  although  Du  Maurier,  in  the  influence 
which  Svengali  exercises  over  Trilby,  makes  an  exception  to  this  ride. 

The  lay  public  has  feared  that  under  the  influence  of  suggestion  an 
evil-minded  person  might  suggest  to  another  the  commission  of  a  crime, 
and  that  the  hypnotized  subject,  deprived  of  his  free  will,  •would  forth- 
with proceed  to  obey  the  suggestion.  In  medical  circles  sham  murders 
(with  wooden  daggers)  have  been  committed  in  obedience  to  su(!h  a  sug- 
gestion. The  possibility  of  actual  murder  being  committed  cannot  be 
denied.  The  practice  should,  therefore,  be  limited  by  law,  and  public 
exhil)itions  should  be  entirely  prohibited.  But,  fortunately,  no  serious 
crime  has  as  yet  been  committed,  to  my  knowledge,  in  obedience  to  an 
hypnotic  suggestion,  and  the  efforts  to  prove  hypnotic  influences  in 
recent  French  trials  have  failed  utterly.  There  is  eA'er}^  probability, 
too,  that  the  instigator  to  such  a  crime  could  be  easily  detected  if  the 
subject  were  rehypnotized  by  a  competent  person  or  commission  ap- 
pointed for  this  purpose.  In  the  hypnotic  state  information  or  hints 
Avould  be  given  which  would  lead  to  the  discovery ;  in  the  interval  be- 
tween such  states  the  subject  would  be  ignorant  of  everything  that  had 
occurred.     The  suggestions  nuide  with  e^dl  intent  dming  the  waking 


iy.'s.L\iTy  AM)  cniMi:.  21  ;i 

state  arc  still  of  far  greater  importance  than  those  issued  to  a  liypno- 
tizecl  iiuUvidual. 

Before  ('oiicludiiig  this  artic'le,  the  writer  wishes  to  impress  upon  the 
medical  man  and  the  jurist  the  following  considerations: 

In  determining  the  (question  of  responsibility  of  an  individual,  the 
older  tests  of  knowledge  of  right  and  wrong,  of  free  will,  of  premedita- 
tion, should  be  disregarded  altogether.  The  only  duty  the  medical 
expert  has  is  to  state  and  to  prove  whether  the  accused  was  or  was  not 
insane  when  the  act  was  committed.  To  strengthen  such  evidence  he 
should  be  able  to  state  the  symptoms  pointing  to  a  special  form  of  insan- 
ity, as  he  would  l)e  expected  to  state  them  in  a  case  of  pneumonia  or 
any  other  purely  i)hysical  disease. 

Insanity  should  be  a  sufficient  excuse  for  crime,  whether  or  not  a 
sane  mind  can  fathom  the  relation  l)etween  the  insane  condition  and  the 
criminal  act. 

Crime  committed  liy  persons  addicted  to  alcohol,  morphine,  cocaine, 
or  any  other  poisonous  drug  can  be  excused  only  if  such  addiction  has 
led  to  the  development  of  a  distinct  form  of  insanity, 

EXAMINATION   OF   INSANE   CRIMINALS. 

A  word  only  with  reference  to  the  proper  method  of  examining  in- 
sane criminals.  The  method  employed  shoidd  be  very  much  the  same 
as  with  other  insane  patients,  bearing  in  mind  that  among  the  crinnnal 
classes,  or  those  accused  of  crime,  simidation  is  very  much  more  fre- 
quent. But  as  simulation  is  discussed  by  another  author  I  may  disre- 
gard it  altogether.  In  examining  a  patient  or  criminal,  take  note  first 
of  his  surroundings,  of  his  apjiearance,  of  his  behavior  before  you 
enter,  and  while  you  are  with  him.  Note  whether  he  behaves  under  ex- 
amination as  any  otlier  insane  person  would,  and,  al)ove  all,  a  person 
with  the  same  form  of  insanit3^  If  the  examiner  has  had  considerable 
experience  in  insanity  it  wiU  be  possible  for  him  to  speak  very  definitely 
on  this  point. 

A  few  years  ago  the  writer  was  asked  to  see  a  prisoner  who  had  en- 
tered the  plea  of  insanity  for  his  ndsdeeds  in  the  commercial  world.  He 
pretended  to  be  suffering  from  delusions  of  persecution,  and  refused  to 
take  the  prison  food,  lie  insisted  on  cooking  his  own  food,  but  took 
very  freely  some  nu'dicine  (an  hypnotic)  prescribed  by  the  prison  physi- 
cian— the  very  last  thing  an  insane  individual  would  have  done.  Instead 
of  referring  to  his  persecutions,  or  of  explaining  win'  he  should  be  perse- 
cuted, he  kept  on  saying  that  his  head  ached  ;  that  "  if  he  could  get  down 
to  Wall  Street  he  would  make  it  all  right  again."  The  man  who  spoke 
so  freely  under  exannnation  in  private  maintained  absolnte  silence  and 
indifference  in  court.  The  discrepancy  between  his  behavior  and  that 
of  tlie  truly  insane  with  such  delusions  was  so  different  that  there  was 
little  doubt  of  simulation. 

It  is  best  to  enter  upon  the  delusions  of  the  insane,  and  to  converse 
freely  with  them,  as  though  the  examiner  were  convinced  of  the  truth 
of  the  premises.  Avoid  leading  questions,  but  try  to  follow  along  the 
line  of  argument  adopted  by  the  insane,  and  in  this  way  the  faidty  rea- 


214  -i  systjlM  of  legal  medicixe. 

souiug  and  faulty  judgment  will  be  easily  detected.  It  requii-es  great 
patience  on  the  part  of  tlie  examiner,  more  especially  in  those  eases  in 
which  the  person  examined  refuses  to  talk.  As  with  the  non-criminal  in- 
sane, the  conversation  has  to  be  begun  again  and  again,  or  repeated  visits 
made,  before  a  successful  result  is  reached. 

In  some  cases  it  may  be  necessary  for  the  physician  to  disguise  his 
own  person,  or  to  appear  under  some  assumed  name  and  in  an  assumed 
function,  but  the  dignity  of  the  profession  requires  that  this  should  be 
avoided  whenever  possible.  Often,  indeed,  the  very  conduct  of  a  person 
knomng  himself  under  examination  gives  the  best  clew  to  the  actual 
mental  condition. 

The  crime  of  which  the  person  is  accused  should  form  the  chief  but 
not  the  sole  topic  of  conversation,  and  the  examiner  must  endeavor  to 
get  at  the  motives  which  inspii-ed  the  criminal  act;  also  whether  the 
accused  feels  any  remorse,  whether  he  would  have  the  deed  undone. 
And  after  this  topic  has  been  exhausted  a  general  examination  should 
be  made  with  the  view  of  determining  the  person's  mental  capacit}-,  his 
knowledge  of  other  events,  his  memory,  and  his  moral  as  weU  as  rehgious 
views. 

The  physical  exa,mination  is  equally  important :  the  formation  of  the 
skull,  his  physiognomy,  the  action  of  the  pupils,  the  x^resence  or  absence 
of  tremor,  his  speech,  his  wi-iting,  his  gait,  Ms  heart,  his  general  physical 
condition — all  these  points  should  be  carefully  noted,  and  will  help  to 
form  a  definite  opinion  of  the  individual's  mental  status.  But  the  sint 
qua  non  of  a  successful  examination  is  that  the  examiner  should  know 
what  to  look  for,  and  that  he  should  have  had  previous  experieuce  ^vith 
the  non-criminal  insane. 


BIBLIOaRAPHY.* 

Allison,  "Am.  Journal  of  Insanity,"  Jxily,  1894. 

Baer,  "Der  Verbveeher  in  anthropologiseber  Bezieliung."     Leipzig,  1S93. 

BenediJct,  "  Kraniometrie  u.  Keplialometrie."     Lectures.     Vienna,  1888. 

Benedikt,  article  on  "  Cranial  Measurements  "  in  "  Eulenburg's  Enevklopadie." 

JBucknill  and  Tul-e,  "  Manual  of  Psychological  Medicine." 

Casper-Liman,  "Handbueli  der  gericbt.  Med.,"  7tb  ed. 

Charcot,  "  Maladies  du  Systeme  Nerveux  :  Iconographie  Salpetriere."   Progres  medical 

of  the  last  ten  years — chiefly  for  hysteria  and  h^iDnotism. 
Clarle,  "Heredity  and  Crime  in  Epileptic  Criminal  Brain,"  1880. 
Contagne  ct  Bernard,  "Arch,  de  I'Anthropol.  Crira.,"  vol.  v.,  Xo.  25. 
CrotJiers,  various  articles  in  the  "Journal  of  Inebriety,"  edited  by  him. 
Despine,  "Psychologie  Naturelle."    Paris,  1868-70.     3  vols. 
Dufonr,  "  Virchow's  Jahresschr,"  1888,  vol.  i.,  p.  64. 
Ellis,  "The  Criminal,"  "Contemporary  Science  Series." 

Erlenniei/er,  "  Morpliimnsueht"  (Morphine  Habit").    Monograph.    3d  ed.    Berlin,  1887. 
Esquiroi,  "Malad.  Mentales,"  1838.     Still  worth  consulting. 
Griesinger,  "Pathologie  u.  Therapie  der  Psychisehenkrank.,"  2d  ed.,  1861;  Sydenham 

ed",  1867. 
Hack-Tiike.     London,  1891. 

*  This  is  not  intended  to  be  a  complete  list,  but  to  include  such  works  as  have 
been  considted  in  the  preparation  of  this  article,  and  those  which  the  alienist  or  the 

jurist  would  do  well  to  consult  in  further  studies  on  this  subject. 


BiBLWunAriJY.  215 

Hammond,  "Treatise  on  Insanity,"  1883. 

Hirsch,  "  Genie  uud  Eutuitung."    Berlin  and  Leipzig,  1894.    Contains  critical  studies 

in  opposition  to  Lonibroso's  theories. 
Huchanl,  "  Caraetei-e,  Moeurs,  etc.,  du  Hysteriques."      "Arch.  d'Xeurologie,"  March 

and  April,  1882. 
Jollji,  article  on  "H\'steria"  in  "  2ienissen'.s  Cyclopaedia." 
Kane,  "Alienist  and  Neurologist,"  Jnly,  1882. 
lufchhoj)',   "  Lehrb.   d'Psych.,"  1892.     Am.  ed.  by  Wood  &  Co.      Contains  excellent 

piiotograpliie  reproductions  of  insane  faces. 
Koshr,  "Irreiifreund,"  1875. 
Krat/t-Ehiiu/,   "  Gericlitliche  Psyehopathologie,"  3d  ed.,  1892.     A  very  full  treatise, 

with  ample  references.     See  also  communications  in  "  Friederich's  Blatter,"  1872 

and  later  years. 
Eurella,  "  Naturgeschiehte  des  Verbrechers."    Stuttgart,  1893. 
Lawson,  "  Insanity  as  a  Defense  to  Crime."     St.  Louis,  1884.     An   excellent  legal 

summarj\ 
Legrand  du  SaulJe,  "La  Folic." 
Legrand  da  Saidle,  "  Etude  Med. -Leg.  sur  I'Hysterie  et  sur  le  Degr6  de  EesponsabUit^," 

etc.     "Gaz.  des  Hop.,"  1859. 
Lloj/d,  "Journal  of  Nervous  and  Mejital  Dis.,"  188G. 
Lombroso,  "  L'Uomo  Delinquenti  in  Eapporto  all,  Antropologia  Giurisprudenza,"  etc., 

3d  ed.,  1884.  German  translation  by  Fraenkel.  Hamburg,  1887. 
Lombroso,  "  Neue  Fortsehritte,"  etc.  German  transl.  Leipzig,  1894. 
Lowenfeld,  "Neurasthenie  u.  Hysterie."     Wiesbaden,  1894. 

Maudsley,  "Responsibility  in  Mental  Diseases,"  4th  ed.     D.  Appleton  &  Co.,  1881. 
Mendel,  "Dementia    Paralytica."     Berlin,  1880.     Also   article   on  "Moral  Insanity," 

"Eulenburg's  Encyklop.,"  1888. 
Meyer,    L.,    "Die     Stellung    der    Geisteskrank.,    etc.,"   zur    Kriminalgesetzgebung." 

"Arch.  f.  Psych,  u.  Nervenk.,"  1870,  vol.  ii. 
JlfeyHe>-f,  "Gehirn  u.  Gesittuug."    Vienna,  1889.    Lectui'e.    Also  "  Psvchiatiy  "  (transl. 

by  Sachs),  1885. 
Moeli,  "  Ueber  irre  Verbrecher,"  1888. 
Morel,  "Traite  des  Malad.  Ment.,"  1860. 

mcolson,/' The  Morbid  Psychology  of  Criminals."     "J.  of  Ment.  Sc,"  1874,  vol.  xx. 
Prichard,    "  Treatise    on    Insanity,"   1835.      With    especial   reference   to   moral  in- 
sanity. 
liaii,  "  Treatise  on  the  Medical  Jurisprudence  of  Insanity,"  1860,  4th  ed. 
liohlnson,  W.  R.,  "Journal  of  Nervous  and  Mental  Dis.,"  May,  1887. 
Hush,  B.,  5th  ed.,  1835. 

Sachs,  B.,  "What  the  Law  can  Do  to  Mitigate  the  Evils  of  Medical-Expert  Testi- 
mony."    "N.  Y.  Med.  Examiner,"  July,  1892. 
JSauder  and  Eicliter.  "Geistesstorung  u.  Verbrechen."     Berlin,  1886. 
Schiile,  "Psychiatrie,"  1878. 
Smith,  A.,  "On  the  Position  of  the  Medical  Fraternity  with  Reference  to  the  Abuse 

of  Alcohol."     "Berl.  Klin.  Wochenschr.,"  1894,  No.  31. 
Sommer,  "Beitrage  zur  Kenntniss  der  kriminellen  In-en."    "Allg.  Zeitsehr.  f.  Psych.," 

1884,  pp.  88  et  seq. 
Sommer,  "Ueber  Trunksucht."    Konigsberg,  1888. 
£pif~ka,  "Insanity:  Its  Classification,"  etc.,  1883. 
JStriimjycll,  "Die  Alkoholfrage  vom  aerztlichen  Standpimkte."     "Berliner  Kl.  Wocli- 

enschrift,"  1893,  No.  39. 
Taguet,  "Du  Suicide  dans  I'Hysterie."     '-'Annales  M^d.-Psyehologiques,"  May,  1877. 
Tardieu,  "Etude  Med. -Legale  sur  la  Folic."     Paris,  1892. 
Tliompson,  "Journal  of  Ment.  Science,"  January,  1870. 
Thompson,  "Psychology  of  Criminals."     "J.  of  Ment.  Sc,"  vol.  xvi. 
Westphal,  "Arch.  f.  Psychiatrie,"  vol.  iii.  and  vol.  ■yii. 
Wharton  and  Stille's  "Med.  Jimsprudence,"  3d  ed.,  1873,  vol.  i. 


ON  THE  RELATIONS  OF  MENTAL  DEFECT  AND  DIS- 
EASE  TO   CEIMINAL   RESPONSIBILITY. 

By  LOUIS  E.  BINSSE. 
THE   THEORY  OF   CRIMINAL  RESPONSIBILITY. 

The  criminal  law  of  Eugiaud  recognized  at  an  early  day  the  existence 
of  mental  defect  and  disturbance,  and  in  a  rude  and  nnscientific  way 
attempted,  according  to  the  methods  of  the  medical  science  of  the  time, 
a  classification  of  its  varieties  and  degrees. 

Coke,  in  the  Commentary  on  Littleton  (Co.  Lit.  246&,  247a)  and  in 
Beverley's  Case  (4  Co.  Rep.  123&),  makes  the  following  distinctions: 
"  Here  Littleton  explaineth  a  man  of  no  sound  memorie  to  be  non  com- 
2)os  mentis.  Many  times  (as  it  here  appeareth)  the  Latin  word  explain- 
eth the  true  sense,  and  calleth  him  not  atnens,  dentens,  ft(riosus,  houificus, 
fatims,  stidtns,  or  the  like,  for  iton  compos  mentis  is  most  sm-e  and  legall. 
Non  compos  mentis  is  of  four  sorts :  1.  Ideota,  which  from  his  nativitie, 
by  a  perpetnall  infirmitie,  is  no)i  compos  mentis.  [Idiot  or  fool  natural.] 
2.  Hee  that  by  sicknesse,  griefe,  or  other  accident,  whoUy  loseth  his 
memorie  and  understanding.  [He  who  was  of  good  and  sound  memory, 
and  by  the  visitation  of  God  has  lost  it.]  3.  A  lunatic  that  hath  some- 
time his  understanding  and  sometime  not,  aliquando  gandet  Jucidis  inter- 
valliSj  and  therefore  he  is  called  non  compos  mentis  so  long  as  he  hath 
not  understanding.  [Luncdicus,  qui  gandet  lucidis  intervdlJis,  and  some- 
times is  of  good  and  sound  memory,  and  sometimes  non  compos  mentis.] 
4.  Lastly,  hee  that  by  Ids  owne  vitious  act  for  a  time  depriveth  himselfe 
of  his  memorie  and  understanding,  as  he  that  is  drunken."  [By  his  own 
act,  as  a  drunkard.] 

At  a  later  day,  Sir  Matthew  Hale  (Hale,  P.  C,  chap,  iv.)  made  a  simi- 
lar but  more  detailed  classification. 

Mental  defect  and  disease  he  called  dementia,  the  state  of  being  out 
of  one's  mind.     This  he  divided  into  three  great  classes : 

I.  Natural  dementia,  that  is,  idiocy,  or  fatuity  from  birth. 
II.  Accidental  dementia  or  insanity. 

III.  Voluntary  dementia  or  drunkenness. 

In  the  second  of  these  classes,  that  of  insanity,  he  distinguished  total 
from  partial  insanity ;  the  latter  being  partial  in  respect  to  its  subjects, 
or  partial  in  respect  to  its  degrees.  He  further  took  note  that  it  was,  as 
to  its  nature,  at  one  time  permanent,  at  another  time  occasional.  Tlie 
former  he  called  phrenesis  or  madness,  the  latter  lunacy,  from  tlie  con- 
temporaneous error  that  mental  disease  was  influenced  by  the  phases  of 

217 


218  ^   SYSTEM    OF  LEGAL   MEDICINE. 

the  moon.  In  addition  to  the  ijiere  loss  of  the  use  or  exercise  of  reason, 
he  recognized  tlie  furtlier  condition  of  a  superadded  state  of  violence  or 
fury.     This  he  called  furor,  rabies,  or  mania. 

However  unacceptable  these  classifications  may  be  to  advanced  medi- 
cal science  (Prichard  On  the  Different  Forms  of  Insanity,  London,  1842, 
p.  9),  the}^  form  the  necessary  basis  of  anj^  consideration  of  the  subject 
from  the  legal  point  of  view,  for,  up  to  the  time  of  the  answers  given  by 
the  judges  of  England  to  the  questions  put  them  by  the  House  of  Lords 
in  consequence  of  the  acquittal  of  Daniel  McNaghten  (10  CI.  &  Fin.  200), 
the  writings  of  Coke  and  Hale,  together  with  the  instructions  given  by 
judges  in  particular  cases,  constituted  the  exclusive  authorities  on  this 
subject. 

Although  the  law,  speaking  thus  through  its  sages,  has  attempted  to 
classify  according  to  the  methods  of  medical  science  mental  defect  and 
disturbance  in  its  varieties  and  degrees,  it  contemplates  them  from  an 
altogether  differing  standpoint.  Medical  science  deals  with  the  causes 
of  mental  disease  and  seeks  knowledge  on  the  subject  for  a  piirely  medi- 
cal end.  With  it  an  inquir^^  as  to  the  fact  of  insanity  is  an  absolute  and 
final  one.  The  law,  on  the  other  hand,  neglects  the  causes  of  insanity 
and  deals  exclusively  with  its  consequences,  which  are  evidenced  by  con- 
duct, the  outward  expression  of  the  inner  mental  state.  From  this  point 
of  view  there  are  two  forms  of  insanity — the  one  that  causes  a  man  to 
break  the  law,  the  other  that  does  not  cause  him  to  do  so.  The  fact  of 
insanity  is  not  therefore  in  the  mind  of  the  law  the  ultimate  end  of  its 
investigation,  but  one  relative  to  the  broader  inquiry  as  to  the  fact  of 
responsibility  or  punishabilitj^  Even  in  respect  to  this  the  two  sciences 
have  different  starting-points :  the  one,  beginning  with  the  fact  of  dis- 
ease, seeks  to  measure  its  disturbing  influence  qu  the  conduct  of  particu- 
lar members  of  the  community  governed  by  a  code  of  moral  and  social 
obligation ;  the  other,  at  the  opposite  end,  sets  out  from  the  standpoint 
of  moral  and  social  requirements  and  assumes  that  all  men  are  sane, 
and  consequently  responsible  for  their  acts  until  in  individual  cases 
they  are  proved  not  to  be  so.  (Minshall,  J.,  State  vs.  Bowslier,  3  Cin. 
Law  Bui.  187 ;  Curtis,  J.,  U.  S.  vs.  McGlue,  1  Curtis,  1 ;  "  Responsibility 
in  Criminal  Cases,"  by  David  Nicholson,  M.D.,  Jonr.  of  Mental  Sci.,  vol. 
xxiv.,  p.  1 ;  "  On  the  Relation  of  Madness  to  Crime,"  by  J.  C.  BuckniU, 
M.D.,  Am.  Jour,  of  Insanity,  vol.  xl.,  p.  412.) 

In  a  criminal  trial,  when  mental  defect  or  disease  is  pleaded  as  a 
defense,  the  question  is  "  whether  the  accused  be  guilty  or  not  guilty." 
(Mr.  Justice  Maule,  McNaghten's  Case,  supra.)  In  this  fact  of  guilt  is 
involved  the  fact  of  the  evil  mind,  for  although  the  criminal  law  takes 
cognizance  only  of  the  exterior  act  (Montesquieu,  Esprit  des  Lois,  chap. 
xi.),*  and  not  of  the  mere  interior  intention,  yet  it  is  a  fundamental 
maxim  that  "  the  act  itself  does  not  make  a  man  guilty,  unless  his  inten- 
tion were  so."     (3  Inst.  107.)t 

A  criminal  act  is  therefore  complete  only  when  the  evil  mind  concurs 
with  the  outward  act ;  and  in  the  iiu|uiry  as  to  the  existence  of  this  evil 
mind,  the  fact  of  mental  defect  or  disturbance  is  pertinent,  as  a  traverse 
of  the  evil  mind's  essential  constituents,  of  will,  intention,  or  malice. 

*  "Les  lots  ne  se  chargent  de punir  que  les  actions  exterienres." 
t  "Actus  nonfacit  reum  nisi  mens  sit  rea." 


MENTAL   RESPONSIBILITY  IN  CHIMIN  J  L    CASES.  210 

(Stei)lieii'.s  General  View  of  the  Cnmimd  Laiv  of  Eiif/Jiiii(l,  chap,  iii., 
p.  8G.)  lu  notliin^  more  than  this  has  the  law  appreciated  the  futility 
and  peiil  of  definition,  the  impossibility  of  defining  or  describing  the 
disease  or  of  hiving  down  any  test  of  its  existence.  (Lord  Lyndliiu'st^ 
Hansard's  Debates,  vol.  Lxvii.,  third  series,  p.  716 ;  Lord  Denman,  lie(/ina 
vs.  Oj-fonl,  9  C.  &  P.  525.)  It  has  therefore  refrained  from  making  a 
special  issue  of  the  fact  of  insanity  and  has  limited  itself  to  the  estab- 
lisinnent  of  a  canon  of  responsi])ility,  legal  insanit}^  being  commensu- 
rate with  legal  irresponsil)ility.  "  Our  law  was,"  says  Erie,  C.  J.,  "  that  a 
man  was  responsible  for  liis  acts  unless  his  mind  Avas  in  a  state  which 
prevented  Mm  from  being  responsible  for  his  acts.  If  he  was  conscious 
that  he  was  doing  wrong  at  the  time  when  he  committed  the  act  then 
he  was  responsible.  .  .  .  The  question  was  whether  he  was  or  was- 
not  responsil)le  when  he  committed  the  act — not  whether  he  was  not 
guilty  on  the  ground  of  insanity :  that  was  an  issue  far  too  vague,  indefi- 
nite, and  undefined.  The  issue  was,  whether  or  not  when  he  did  the  act 
he  was  legally  responsilile — in  other  words,  whether  he  knew  its  nature, 
and  knew  that  it  was  ^vi'ong."  {Eegina  vs.  Leigh,  -4  F.  &:  F.  915,)  The 
distinction  thus  made  between  insanity  and  responsibility  marks  thfr 
boundaries  of  the  separate  and  distinct  pro\dnces  of  law  and  medicine. 
Tlie  ditfereuce  between  mental  health  and  disease  is,  and  must  remain,  a 
fact  of  science  entirely  within  the  purAnew  of  medicine.  On  the  other 
hand,  the  determination  of  the  relation  of  mental  disease  to  guilt,  and  to 
the  punishaliility  of  such  guilt,  and  of  the  point  of  separation  between  the 
conditions  of  responsibility  and  ii-responsibility,  must  be  the  exclusive 
function  of  the  law.  '-The  question,"  says  Sir  J.  F,  J.  Stephen,  "AMiat 
are  the  mental  elements  of  responsibility  ?  is,  and  must  be,  a  legal  ques- 
tion. It  cannot  be  anything  else,  for  the  meaning  of  responsibility  is 
liability  to  punishment,  and  if  criminal  law  does  not  determine  who 
are  to  be  punished  under  given  circumstances  it  determines  nothing." 
(Stephen's  Hisfori/  of  the  Criminal  Law  of  England,  chap,  xix.,  p.  183.) 
From  the  natm-e  of  things,  the  law  must  determine  for  itself,  and  in  the 
first  place,  whether  or  not  the  fact  of  insanity  should  exempt  one  at  all 
from  the  ordinary  hability  of  the  criminal  law,  and,  ha\dng  admitted  the 
exemption,  it  must  set  and  define  the  limits  of  such  exemption.  For  in- 
stance, as  a  rule  of  policy,  the  law  might  determine  that  no  degree  of 
madness  should  exempt,  or  that  any  degi-ee  of  madness  should  so  ex- 
empt ;  or  it  might  place  the  point  of  responsibility,  as  it  does,  somewhere- 
between  these  two  extremes.  The  Supreme  Court  of  New  Hampshii'e 
{State  vs.  Jones,  50  N.  H.  369),  which  has  gone  to  the  extreme  in  its  rejec- 
tion of  the  legal  criterions  of  responsibility  by  leaving  to  the  jury,  as 
matters  of  fact,  whether  the  accused  had  a  mental  disease,  and  whether 
the  overt  act  was  a  product  of  such  disease,  impliedly  laid  down  the  cri- 
terion of  legal  responsibility  that  no  man  should  be  held  accountable 
criminally  for  an  act  the  offspring  or  product  of  mental  disease.  Ac- 
cording to  the  G-erman  jurist  Casper  the  term  criminal  responsibility  is 
easily  defined,  since  it  is  based  upon  unchangeable  natural  psychological 
laws,  recognized  by  every  man's  conscience,  and  which  may  be  compre- 
hended in  the  following  simple  dogmas :  1.  Both  a  good  and  exil  prin- 
ciple reside  and  act  in  man.  The  recognition  of  this  fact  is  coeval  Avitli 
the  origin  of  man,  and  is  expressed  in  the  most  ancient  religions.  2.  This 
double  principle  itself,  as  well  as  the  power  of  recognizing  it,  is  born  with. 


220  ^   SYSTEM  OF  LEGAL  MEDICINE. 

eveiy  man,  and  is  firmly  based  in  liis  conscience  so  long  as  he  remains 
in  Ills  natiu-al  condition.  3.  Man  in  liis  normal  condition  is  at  perfect 
liberty  to  permit  Mmself  to  be  gnided  in  his  actions  by  either  the  good 
or  the  bad  principle ;  "  he  has  freedom  of  choice,"  according  to  others, 
"  the  power  of  spontaneous  action,"  "  moral  fi'eedom,"  or  "  the  freedom 
of  the  will."  4.  Every  man  knows,  and  so  long  as  he  continues  in  his 
normal  condition  must  be  presupposed  to  know,  that,  in  s]3ite  of  his  free- 
dom of  choice,  he  must  allow  himself  to  be  guided  in  his  actions  by  his 
good  principle,  and  withstand  the  allurements  of  his  evil  one.  5.  And 
that  when  he  acts  reversely  he  exposes  himself  to  the  punishment  of  his 
internal  .judge,  his  conscience,  which  dwells  "s^dthin  him  as  the  natural 
guardian  of  the  laws  of  morality.  These  are  eternal,  inborn  truths,  the 
foundation-stones  of  the  whole  doctrine  of  criminal  responsibility,  to 
which  the  following  may  be  added,  if,  indeed,  they  do  not  actually  belong 
to  the  same  category  :  eveiy  man  li^dng  in  the  bonds  of  society,  who  has 
aiTived  at  the  normal  development  of  his  mental  powers,  has  experi- 
enced and  knows  that  society  is  not  and  cannot  be  satisfied  by  the  pun- 
ishment inthcted  by  his  internal  monitor,  but,  in  accordance  with  the  re- 
quii'ements  of  the  inborn  laws  of  morality,  has  also  laid  down  and  put  in 
execution  external  punishments  for  any  action  opposed  to  morahty.  In 
accordance  with  these  laws,  therefore,  he  must  be  made  responsible  for 
every  rash  deed  so  long  as  he  is  in  the  unclouded  possession  of  his  men- 
tal powers,  since,  in  such  cii'cumstances,  he  is  in  a  position  to  foresee  all, 
even  the  e\-il  results  of  his  actions ;  he  is  possessed  of  criminal  responsi- 
bility. {HandhooTx  of  the  Practice  of  Forensic  Medicine,  vol.  v.,  part  vi., 
chap,  i.,  sec.  58.) 

The  law  of  England,  in  the  same  manner,  places  the  foundation-stones 
of  criminal  responsibility  in  the  intuitions  of  conscience  and  the  enact- 
ments of  positive  law,  in  relation  to  which  it  recognizes  in  the  normal 
man  a  liberty  of  mil,  a  capacity  to  follow  the  one  or  obey  the  other. 
Inasmuch  as  there  can  be  no  liberty  of  will  Avhere  there  is  no  under- 
standing (Hale,  P.  C,  chap,  ii.),  it  has  assumed  the  truth  of  the  correlative 
proposition  that  where  there  is  an  understanding  sufficient  to  know  the 
thing  chosen,  good  and  evil,  the  freedom  of  the  will  exists  to  the  extent 
of  conferring  responsibility.  It  has  placed,  therefore,  the  capacity  to 
form  the  evil  intent  exclusively  in  the  consciousness  or  understanding 
of  the  individual,  making  it  thus  the  touchstone  of  responsibility ;  a  cri- 
terion which  it  applies  to  the  "natm-al  defect"  of  infancy  (Hale,  P.  C, 
chap,  iii.)  as  well  as  to  the  "accidental  defects"  of  idiocy  and  insanity — 
to  those  who  are  nan  compos  mentis.  "  On  the  part  of  the  defense,  it  is 
contended,"  says  Lord  Denman,  "that  the  prisoner  at  the  bar  was  non 
compos  mentis,  that  is  (as  it  has  been  said),  unable  to  distinguish  right 
from  ■s^^:'ong,"  or,  in  other  words,  "  that  from  the  effect  of  a  diseased  mind 
he  did  not  know  at  the  time  that  the  act  he  did  was  wrong."  {Eegina  vs. 
Oxford,  9  C.  &  P.  525.) 

I.  NATURAL   DEMENTIA   OR  IDIOCY. 

Although  Hale  elaborately  distinguishes  idiocy  from  insanity,  there 
would  seem  to  be  no  sufficient  legal  reason  for  this  distinction,  as  the 
consequences  of  the  knowledge  of  the  nature  of  an  act  do  not  vary  with 
causes  purely  physiological  in  their  difference,  such  as  the  difference  in- 


MENTAL   BESrON.^lBlLITY  IN  ClilMINAL    CASES.  221 

•trmsically  motlical  made  between  mental  weakness  and  disease,  and  the 
<lifference  of  origin,  whether  it  be  congenital  or  otherwise.  (Note  1  to 
Article  27,  Steplien's  ])i(j<'st  of  the  Criminal  Jxitv.) 

An  idiot,  "  wliieh  from  his  nativitie,  l)y  a  perpetnall  infirmitie  "  (Co. 
Lit.  247rt),  "  being  nnder  a  natural  disability  of  distinguishing  between 
good  and  evil,  is  not  punishable  by  any  criminal  prosecution  wdiatso- 
■ever."  (Hawk.,  P.  C,  vol.  i.,  pp.  1, 2.)  As  congenital  mental  defect  varies 
infinitely  from  the  condition  where,  "from  an  original  malorganization, 
there  is  the  human  frame  alone  without  the  human  capacity  "  (Erskine, 
Trial  of  James  Hadfield,  27  How.  St.  Tr.  1312),  through  endless  degrees 
•of  imbecility  and  mental  weakness,  this  do(,*trine  in  its  genei-ality  must 
be  limited  to  conditions  of  mind  similar  to  that  set  forth  by  Fitzherbert 
in  his  definition  of  "  an  idiot  as  such  a  person  who  cannot  account  or 
immljer  twenty  pence,  nor  can  tell  who  was  his  father  or  mother,  nor  how 
old  he  is."  (Fitzh.  G,  N.  B.  532.)  Amid  these  degrees  of  imbecihty  and 
mental  weakness,  the  point  of  responsibility  is  found  in  the  capacity  of 
knowing  good  from  evil.  "  The  law  w^ill  not  measure  the  sizes  of  men's 
-capacities,  so  as  they  be  compos  mentis,'^  says  vSir  Joseph  Jekyll  in  the 
Duchess  of  Cleveland's  Case.  (Erskine,  Trial  of  Hadfield,  suj^ra ;  Patterson 
vs.  The  People,  4G  Barb.  G25.)  "The  law  does  not  undertake  to  measiu'e 
the  intellectual  capacities  of  men,"  says  the  Supreme  Coiu't  of  Indiana. 
{Wartena  vs.  The  8tate,  105  Ind.  445.)  "Imbecility  of  mind  may  be  of 
such  a  degree  as  to  constitute  insanity  in  the  eyes  of  the  law,  but  mere 
mental  weakness,  the  subject  being  of  sound  mind,  is  not  insanity,  and 
•does  not  constitute  a  defense  to  crime.  The  law  recognizes  no  standard 
-of  exemption  from  crime  less  than  some  degree  of  insanity  or  mental 
unsoundness.  Immunity  from  crime  cannot  be  predicated  upon  a  merely 
-weak  or  low  order  of  intellect  coupled  wdth  a  sound  mind.''  ( Con  ivai/  vs. 
The  State,  118  Ind.  482.) 

Sir  James  F.  J.  Stephen  questions  the  responsibility  in  law  of  one  who, 
knowing  in  a  way  the  nature  and  qualit}-  of  an  act,  and  knowing  that  it 
is  wrong,  yet  through  mental  imbecility  is  unable  to  form  such  an  esti- 
mate of  its  nature  and  consequences  as  a  i^erson  of  ordinary  intelligence 
would  form.  {Digest  of  the  Criminal  Law,  Illustration  2,  Article  27.)  In 
■Coiuiecticut  one  confessedly  neither  idiotic  nor  insane  was  tried  for  the 
burning  of  a  barn.  In  charging  as  to  his  responsibihty,  the  trial  judge 
practically  took  the  measm-e  of  his  capacity,  w^hicli  he,  the  judge,  likened 
to  that  of  a  very  young  child.  Under  these  instructions,  the  accused  was 
promptly  acquitted.     {State  vs.  Eichards,  39  Conn.  591.) 

Juries  have  even  gone  beyond  this  point,  and  in  the  weighing  of 
responsibility  have  manifestly  taken  into  account  the  weakness  of  the 
human  intellect  as  contrasted  with  the  force  of  human  impulse  or  passion. 

At  York,  England,  in  the  year  1859,  one  James  Atkinson,  aged  twenty- 
four,  was  tried  for  the  murder  of  a  young  woman,  whose  tlu'oat  he  had 
cut,  there  being  eight  distinct  wounds.  There  could  be  no  question  as 
to  his  appreciation  of  the  natm-e  of  the  act  and  its  consequences.  After 
the  commission  of  the  deed  he  hid  the  knife  in  a  wall,  washed  his  bloody 
liands  in  a  pond,  and  on  the  following  day  informed  a  brother  that  he 
had  killed  his  sweetheart.  He  could  read  and  T\'iite,  and  had  done  some 
arithmetic.  Despite  the  instructions  as  to  the  criterion  of  responsibility 
based  upon  the  knowledge  of  right  and  wr<nig,  he  was  a.cqiiitted  by  the 
jm-y  on  the  groinid  of  insanity,  evidently  on  the  medical  testimony  that 


222  A   SYSTEM   OF  LEGAL  MEDICINE. 

being  of  weak  intellect  he  bad  not  reasonable  control  over  Ms  actions  and 
conld  not  be  held  resi3onsible  as  other  men.  ("  Insanity  and  Crime,"  by 
S.  W.  North,  M.R.C.S.,  vol.  xxsii.,  Journal  of  Mental  Science,  p.  163.) 

As  the  senses  are  the  avenues  wherebj^  ideas  are  conveyed  to  the  mind^ 
and  speech  is  the  ordinary  faculty  given  for  their  expression,  the  condi- 
tion of  deaf -mutism  reverses  the  presumption  of  sanity,  and  casts  upon 
the  prosecution  the  burden  of  proving  the  responsibility  of  the  accused, 
{The  Bate  vs.  Draper,  1  Houst.  Crim.  Rep.  [Del.]  291.) 


n.   ACCIDENTAL    DEIMENTIA    OR    INSANITY. 

(a)  Total  Insanity. — Like  idiocy,  a  condition  of  total  insanity  is  a. 
complete  bar  to  criminal  responsibility.  "He  that  is  non  compos  mentis 
and  totally  deprived  of  all  compassings  and  imaginations  cannot  com- 
mit high  treason  by  compassing  or  imagining  the  death  of  the  king ;  for 
furiosus  solo  furore  jntmtur;  but  it  must  be  an  absolute  madness  and  a. 
totaU.  deprivation  of  memorie."  (3  Inst.  6.)  As  concerning  such  condi- 
tions there  can  be  but  one  judgment ;  they  need  no  extensive  considera- 
tion from  medical  jurisprudence.  Even  when  the  law,  in  its  extreme- 
rigidity,  required  that  the  insanity  should  extend  to  "  the  deprivation  of 
aU  compassings  and  imaginations,"  to  the  "  state  of  total  furiosity,"  it  did 
not  also  require  it  to  be  continuous  in  respect  of  time.  "  The  quality  of 
the  deed  depends  entirely  on  the  man's  state  of  mind  at  the  time  he  does- 
it,  so  that  whether  his  malady  is  constant  and  unremitting,  or  only  re- 
turn at  intervals,  stilL  his  defense  shall  be  equally  available  if  he  was 
then  utterly  furious  and  void  of  reason."  (Hume's  Commentaries  on  the 
Law  of  Scotland,  chap,  i.,  p.  39;  Trial  of  Sii^A.  Kinloch,  25  How.  St.  Tr. 
891.) 

Lucid  Intervals. — The  truth  of  the  converse  of  this  doctrine  would 
seem  to  be  manifest.  If  an  interval  of  total  madness  should  relieve  from 
responsibility,  an  intermission  or  an  interval  of  restoration  to  sanity 
should  impose  it.  The  fact  of  the  occurrence  of  this  intermission  or 
interval  of  restoration,  called  a  lucid  interval,  was,  owing  to  defective 
medical  knowledge,  so  embedded  in  the  jurisprudence  of  the  time  that 
its  existence  marks,  as  has  been  shown,  tlie  legal  distinction  drawn  be- 
tween two  classes  of  non  competes  mentis,  and  the  difference  between  mad- 
ness and  lunacy.  Owing  to  this  view  that  there  was  a  particular  form 
of  insanity,  the  distinctive  and  essential  characteristic  of  which  was  the 
occurrence  of  lucid  intervals,  in  the  early  cases  great  stress  was  laid 
upon  the  mental  state  of  the  accused  at  the  very  occurrence  of  the  act. 
In  the  case  of  Edward  Arnold  (16  How.  St.  Tr.  695),  Sergeant  Darnell 
for  the  Crown  insisted  that  the  insanity  of  the  accused  should  be  reck- 
oned at  the  time  he  did  the  deed :  "  If  he  hath  intervals  and  kiUs  a  man 
in  those  intervals,  he  is  as  much  subject  to  the  law  as  any  other  nian.'^ 
And  mth  this  was  Justice  Tracy  agreed :  "A  man  that  is  an  idiot,  that 
is  born  so,  never  recovers,  but  a  lunatic  may,  and  hath  his  intervals  j 
and  they  admit  he  was  a  lunatic.  You  are  to  consider  what  he  was  at 
this  day  when  he  committed  this  fact."  In  Hadfield's  Case  (supra),  the 
attorney- gen  era!  made  the  same  contention,  and  the  presiding  justice^ 
Lord  Kenyon,  at  the  conclusion  of  the  trial,  after  admitting  that  the 
accused  was  insane  both  before  and  after  the  act,  and  that  it  was  im- 


MENTAL  RESPONSIBILITY  IN  CRIMINAL    CASES.  22." j 

prolmblo  that  he  liad  recovered  his  senses  in  tlie  interim,  declared  that, 
were  they  to  run  into  nieety,  proof  inig-ht  Ix;  deiiianded  of  Ids  iiisanity  at 
the  precise  moment  wlien  the  act  was  cominitted.  (1  Coll.  Lun.,  ]).  488.) 
Sir  James  Mansfield  charged  the  jnry  in  Bellingham's  Case  (1  Coll.  Lnn., 
p.  63G)  that  there  was  another  species  of  madness,  in  which  persons  were 
subject  to  temporaiy  parox_ysms,  in  which  they  were  g'uilty  of  acts  of 
extravagance,  which  was  called  lunacy;  that  if  these  persons  were  tO' 
conunit  a  crime  when  they  were  not  afflicted  with  the  malady  they  would 
be  to  all  intents  and  purposes  amenable  to  justice.  As  to  this  Hale  was 
no  less  precise  and  distinct :  ">Such  jjersons  as  have  their  lucid  int(irvals 
(which  ordinarily  happens  between  the  full  and  change  of  the  moon)  in 
such  intervals  have  usually  at  least  a  competent  use  of  reason,  and  crimes 
committed  b}^  them  in  these  intervals  are  of  the  same  nature,  and  subject 
to  the  same  punishment,  as  if  they  had  no  such  deficiency."  (Hale,  P.  C, 
chap,  iv.,  p.  31.)  That  the  occurrence  of  the  lucid  interval  constituted  in 
the  mind  of  the  law  a  restoration  to  reason,  or  to  the  competent  use  of 
it — in  otliei'  words,  a  tem])orary  cure — seems  plain  from  the  authorities. 
Lord  Thurlow  {Affo)-iiPi/-General  vs.  Farnther,  3  Bro.  Ch.  441)  defined  a 
perfect  interval  not  to  be  a  cooler  moment,  an  abatement  of  pain  or 
violen(;e,  or  of  a  higher  state  of  torture,  a  mind  relieved  from  excessive 
pressure,  but  an  interval  in  which  the  mind,  having  thrown  otf  the  dis- 
ease, has  recovered  its  general  habit.  And  Baron  Rolfe,  in  liegina  vs. 
Latjtou  (4  Cox,  C.  C.  149),  instructed  the  jury  'Hhat  such  was  the  natiu'e 
of  the  mind  that  it  might  be  one  minute  sane  and  the  next  insane."  If 
such  were  the  real  and  essential  character  of  a  lucid  interval,  there  could 
be  no  just  criticism  of  the  criterion  of  responsibility  based  upon  its  occur- 
rence; but  the  current  legal  view  as  to  its  intrinsic  nature  has  been 
vehemently  disputed  by  mental  phj^sicians,  some  of  whom  deny  alto- 
gether its  existence,  and  others  regard  it  as  being  only  a  remission,  not 
an  intermission,  of  the  disease — an  abatement  of  the  severity  of  the  symp- 
toms, not  a  temporary  cure.  (Ray's  Jurisprudence  of  lusanifi/,  chap,  xv.) 
The  question,  however,  has  only  a  s^^eculative  interest  in  forensic  medi- 
cine. In  the  year  1816,  at  a  Court  of  General  Sessions  held  in  the  city 
of  New  York,  one  Clark  was  convicted  of  petty  larceny  alleged  to  have 
been  committed  during  a  lucid  interval  (1  C.  H.  Rec.  176).  This  case, 
however,  cannot  be  considered  a  precedent,  and  it  is  authoritatively 
asserted  that  the  books  contain  no  other  record  of  a  similar  cou\'iction. 
(Ray's  Jurisprudence  of  Iiisanifi/,  chajD.  xv.,  p.  427.)  Casper  testifies  to  a 
like  experience  on  the  continent  of  Europe :  "  Experience  teaches  us  in 
regard  to  the  whole  question  of  a  lucid  interval,  what  I  have  never  seen 
stated,  that  practically  speaking  it  is  in  so  far  of  little  importance  that  it 
is  but  S(ddom  mentioned  in  foro.  At  least,  of  hundreds  of  erinunal  cases 
which  I  have  reported  on,  I  have  never  had  to  do  wdtli  one  in  which  the 
question  of  a  lucid  interval  came  in  question  at  all."  {HandbooJc  of  Fo- 
rensic Medicine,  vol.  iv.,  part  vi.,  chap,  ii.,  sec.  78.) 

Epilepsy. — The  occurrence  of  the  epileptic  paroxysm,  which,  con- 
sidered as  an  interval,  is  the  I'cverse  of  the  one  we  have  been  consider- 
ing, cannot  be  inferred  from  the  fact  that  the  accused  Avas  suffering  from 
epilepsy,  a  disease  which  has  a  tendency  to  weaken  the  mind  and  to  ])r()- 
duce  insanity.  In  addition,  proof  must  be  given  of  the  occurrence  of 
the  paroxysm  at  the  very  time  of  the  commission  of  the  deed.  {Conunon- 
icealfh  vs^Bu^cieri,  153  Pa.  St.  535.) 


224  ^  SYSTEM  OF  LEGAL  MEDICINE. 

(b)  Partial  Insanity. — It  lias  been  contended,  npon  the  theory  of  the 
essential  nnity  and  indivisibility  of  the  lininan  mind,  that  there  is  in 
fact  no  insanity  which  can  with  substantial  accuracy  be  described  as  a 
partial  one.  ( Waring  ys.  Waring,  6  Moore,  P.  C.  341.)  In  the  criminal 
law,  however,  there  can  be  no  donbt  as  to  the  authority  of  the  distinc- 
tion made  by  Hale  between  the  conditions  of  total  and  partial  insan- 
ity. The  latter  condition,  wherein  persons  who  labor  under  mental  dis- 
ease with  respect  to  one  or  more  objects,  are  entirety,  or  apparently 
entirely,  rational  with  respect  to  others  (Lord  Lyndhurst,  Hansard's  De- 
bates, vol.  Ixvii.,  third  series,  p.  712),  forms  the  almost  exclusive  subject 
of  inquiry  and  the  exclusive  difficulty  when  insanity  is  interposed  as  a 
defense  in  courts  of  law.  Until  the  acquittal  of  James  Hadfleld  (suj^ra), 
a  condition  of  partial  insanity  was,  to  the  accused,  no  exoneration. 
^'  This,"  says  Hale  (P.  C,  vol.  i.,  p.  30),  "  is  the  condition  of  very  many, 
especially  melancholy  persons,  who  for  the  most  part  discover  this  defect 
in  excessive  fears  and  griefs,  and  yet  are  not  wholly  destitute  of  the  use 
of  reason;  and  this  partial  insanity  seems  not  to  excuse  them  in  the 
committing  of  any  offense  for  its  mt^tter  capital ;  for  doubtless  most  per- 
sons that  are  felons  of  themselves  a.nd  others  are  under  a  degree  of 
partial  insanity  when  they  commit  thee:  offenses."  In  the  earliest  cases 
the  insanity  that  might  acquit  must  extend  to  the  total  deprivation  of 
''understanding  and  memory,"  so  that  the  accused  might  "not  know 
what  he  was  doing  no  more  than  an  infant,  than  a  brute  or  a  wild  beast." 
(Trial  of  Edward  Arnold,  supra.)  This,  derisively  called  the  "wild-beast 
theory,"  had  for  its  basis  the  fact  of  the  comparative  indestructibilitj^  of 
the  capacity  to  know  good  from  evil;  which,  not  being  a  process  of 
thought,  nor  taking  its  origin  in  the  intelligence,  but  much  deeper  in  the 
mind,  in  the  consciousness  itself,  insanity  in  its  highest  degree  alone  can 
■obliterate.  (Casper's  Handhooh  of  Forensic  Medicine,  vol.  iv.,  part  vi., 
chap,  i.,  sec.  63).  "A  child,"  argued  the  attorney- general  in  the  case  of 
Hadfield  (supra),  "  cannot  dispose  of  his  property  in  any  manner  what- 
ever, and  no  man  would  think  he  had  a  capacit}^  for  that  purpose ;  but 
he  has  sufficient  capacity  to  be  guilty  of  a  crime.  Why  i  Because  there 
is  a  natural  impression  upon  the  mind  of  man  of  the  distinction  between 
good  and  evil,  which  never  entirely  loses  hold  of  the  mind  while  the 
mind  has  any  capacity  whatever  to  exert  itself ;  nothing  but  total  and 
absolute  debility  deprives  the  mind  of  any  man  of  that."  And  with  this 
the  inductions  of  mental  medicine  are  agreed :  "  The  sense  of  duty,  the 
feeling  of  right  and  wrong,  is  an  innate  principle  of  the  human  mind 
implanted  by  the  Almighty  and  serving  as  a  sure  foundation  for  the  re- 
sponsibility of  man  for  his  actions ;  which  is  thus  not  left  to  chance  de- 
velopment, but  is  rendered  an  essential  and  neciessary  part  of  human 
nature.  It  seems  needful  to  inquire  to  what  extent  this  abstract  and 
necessary  part  of  human  nature  becomes  capable  of  being  perverted  or 
destroj^ed  under  the  influence  of  cerebro-mental  disease.  It  may  be 
taken  as  an  axiom  that  the  innate  and  essential  princqjles  of  mind  are  ever 
present  tvliere  mind  exists.  It  may  also  be  asserted,  as  the  result  of  obser- 
vation and  experience,  that  in  all  lunatics,  and  even  in  the  most  degraded 
idiots,  whenever  manifestations  of  any  mental  action  can  be  adduced,  the 
feeling  of  right  and  wrong  may  be  proved  to  exist."  (Bucknill  on  Crimi- 
^lal  Lunacy,  p.  59.) 

The  fact  of  the  comparative  indestructibility  of  the  capacity  of  know- 


MENTAL  RESPONSIBILITY  IN  CRIMINAL   CASES.  225 

ing  good  from  evil  furnishes,  as  will  he  shown,  the  essential  i-eason  for 
the  objeetious  advanced  against  it  as  the  exclusive  criterion  of  legal  re- 
sponsibility. From  this  standpoint,  too,  does  the  law  consider  mental 
defect  and  disease  in  the  comparative  relations  of  "  civil  competency " 
and  " criminal  responsibility."  An  infant,  a  man  incompetent  for  ci\il 
affairs  or  the  "constant  duties  of  life/'  ma\',  notwithstanding,  he  crind- 
nally  responsible.  ( Att(n-ney-Ueneral,  Trial  of  Hadlleld,  supra.)  Thomas 
Bowler,  found  guilty  in  the  year  1812  of  willfiUly  and  nirdiciously  dis- 
■charging  a  l)lunderbuss  loaded  with  l>ullets  at  one  Burrows,  was  after- 
ward executed,  altlu)ugh  previous  to  the  comndssion  of  the  deed  he  had 
been  adjudicated  incompetent  for  the  management  of  his  affairs  under 
an  inquisition  in  lunacy.  (1  Coll.  Lun.  673.)  A  hke  doctrine,  founded 
upon  similar  reasons,  is  set  forth  by  the  Continental  juiists:  "The  fact 
that  the  conditions  of  criminal  responsibility  are  inborn  in  man  and  are 
<;onsequently  deeply  rooted  in  the  whole  of  his  psychical  organization, 
while  other  psj'chical  processes  are  the  result  of  education,  of  mental 
cultivation,  of  indoctrination  in  the  ways  of  life,  etc.,  produces  another 
difference,  and  a  most  important  one  in  medico-legal  practice,  between 
•civil  and  criminal  responsibility.  The  latter  occupies,  as  it  were,  a 
higher  position,  and  in  not  a  few  cases  must  be  assumed  to  exist  when 
the  former  must  be  deided.  Of  this  a  whole  class  of  criminals  affords 
an  example ;  I  refer  to  those  very  youthful  culprits  who  are  in  general 
as  yet  incapable  of  exercising  the  civil  rights  of  life,  and  consequently 
possess  no  civil  responsibility,  while  their  iLLegal  evil  deeds  are  carried 
out  with  the  most  perfect  consciousness  of  tlieii*  punishable  character 
and  with  all  the  unquestionable  criteria  of  freedom  of  will,  and  they 
must  therefore  be  declared  to  be  criminally  responsible.  Both  in  the 
science  of  law  and  in  the  practical  administration  of  justice,  so  far  as  I 
am  acquainted  with  them,  this  doctrine  is  assumed  as  indisputable." 
(Casper's  Handhooli  of  Forensic  Medicine,  vol.  iv.,  part  vi.,  chap,  i.,  sec.  58.) 

At  the  present  day,  when  the  law  no  longer  assumes  the  fact  of  the 
survival  of  the  capacity  of  kno-s^ing  good  from  evil,  and  consequently 
that  of  responsibility,  unless  the  mental  wreck  extend  to  a  condition  of 
total  insanity  the  inquiry  becomes  more  subtile  and  difficult.  An  '■  in- 
divisible line  "  may  separate,  as  Hale  says,  the  conditions  of  total  and 
partial  insanity,  but  the  line  is  still  more  "indivisible"  separating  the 
partial  insanity  that  does  fi-om  the  partial  insanity  that  does  not  obscure 
this  capacity,  the  obscuration  being  more  complete  and  consequently 
more  evident,  in  the  night  of  total  than  in  the  clouds  of  partial  insanity. 
For  assuming  that  one  partially  insane  is  capable  of  a  crinnnal  intent, 
what  problem  is  more  perplexing  than  the  question  whether  the  disease 
did  or  did  not  affect  the  act?  (Maudsley's  Kesponsihiiifj/  in  Mental  Dis- 
ease, p.  109),  and  the  further  question  whether  ''  conscious  malice  and 
mischief  did  mix  with  the  insanity"  ?    (Erskine,  Trial  of  Hadfield,  supra.) 

The  application  of  the  canon  of  criminal  responsibility  finds  its  most 
ordinary  expression  in  the  question  left  to  the  jury,  "Whether  at  the 
time  of  the  committing  of  the  act  the  party  accused  was  laboring  under 
3uch  a  defect  of  reason,  from  disease  of  the  mind,  as  not  to  know  the 
nature  and  quality  of  the  act  he  was  doing,  or  if  he  did  know  it  that  he 
did  not  know  that  he  was  doing  what  was  wrong?"  (^leXaghten's  Case, 
supra.)  The  same  canon  has  found  a  variety  of  expressions,  as  the  fol- 
lowing :  "  Did  he  [the  prisoner]  know  when  he  committed  the  act  what 


226  ^   SYSTEM  OF  LEGAL  MEDICINE. 

tlie  effect  of  it,  if  fatal,  would  be  witli  reference  to  tlie  crime  of  murder  f 
Did  lie  know  that  he  was  committiug-  an  offense  against  the  laws  of  God 
and  nature  f "  {Rex  vs.  Offord,  5  C.  &  P.  168.)  "  Whether  the  prisoner  was 
laboring  under  tliat  species  of  insanity  which  satisfies  you  that  he  was 
quite  unaware  of  the  nature,  character,  and  consequence  of  the  act  he 
was  committing,  or,  in  other  words,  whether  he  was  under  the  influence 
of  a  diseased  mind  and  was  really  unconscious  at  the  time  he  was  com- 
mitting the  act  that  it  was  a  crime?"  {Begina  vs.  Oxford,  9  C.  &  P.  525.) 
"■  If,  on  the  other  hand,  he  [the  accused]  well  knew  that  his  act  would 
take  away  life,  that  that  act  was  contrary  to  the  law  of  God  and  punish- 
able by  the  law  of  the  land"  {Regina  vs.  TownJeg,  3  F.  &F.  839),  "the  sin- 
gle question  was  whether,  when  he  [the  accused]  committed  the  offense 
charged  upon  him,  he  had  sufficient  understanding  to  distinguish  good 
from  evil,  right  from  VvTong,  and  that  murder  was  a  crime  not  only 
against  the  law  of  God  but  against  the  law  of  his  country."  (Belling- 
ham's  Case,  supra.)  "  Whether  the  accused  at  the  time  of  doing  the  act 
was  conscious  that  it  was  an  act  which  he  ought  not  to  do."  (Horn- 
blower,  G.  J.,  State  vs.  Bpencer,  1  Zab.  196.)  As  to  the  fli'st  part  of  the 
canon,  the  knowledge  of  the  nature  and  quality  of  the  act,  there  can  be 
little  difficulty,  as  it  contemplates  a  state  of  mind  sufficiently  obvious, 
one  of  complete  overthrow,  or  of  an  illusion  so  complete  as  to  render  the 
mind  insensible  of  the  nature  of  the  act.  (Mr.  Justice  Le  Blanc,  Bowler's 
Case,  supra.)  "  I  can  remember  one  case,  and  one  case  only,"  says  Dr. 
Bucknill,  "  of  a  lunatic  on  trial  for  murder  who  really  did  not  know  the 
natiu'e  and  quality  of  the  act  which  she  had  committed.  It  was  that  of 
a  maniacal  woman  who  had  drowned  her  two  children  in  the  Exeter 
Canal.  She  was  so  mad  when  placed  in  the  dock  that  Mr.  Justice  Cole- 
ridge, father  to  Lord  Coleridge,  saw  that  she  was  unfit  to  plead.  He 
sent  for  his  brother  judge  from  the  Nisi  Prius  Court,  and  well  I  remem- 
ber seeing  the  two  judges  standing  in  their  robes  of  different  color,  and 
talking  low  to  each  other  as  they  looked  at  the  prisoner  and  formed 
their  own  judgment  of  her  mental  state,  and  Mr.  Justice  Coleridge  or- 
dering her  removal  to  the  county  asylum."  Before  the  next  assize  she 
had  completely  recovered,  and  I  again  received  an  order  to  produce  her 
in  court,  and  Mr.  Justice  Coleridge  (for  he  again  was  the  judge),  without 
takiug  any  evidence,  directed  the  jury  to  find  a  verdict  of  'not  guilty^ 
on  the  ground  of  insanity,  and  upon  that  verdict  having  been  given  lie 
ordered  her  to  be  given  to  the  care  of  her  friends."  ("  On  the  Relation  of 
Madness  to  Crime,"  American  Journal  of  Insanity,  vol.  xl.,  p.  412.)  Lord 
Brougham  refers  to  this  same  condition  of  mental  overthrow  and  com- 
plete illusion  in  the  memorable  debate  on  insanity  and  crime  in  the 
House  of  Lords  (March  13, 1843,  Hansard,  vol.  Ixvii.,  third  series,  p.  730) : 
"First  of  all,  did  the  unfortunate  person  know  what  he  was  about? 
Did  he  actually  know  he  was  killing  a  man  f  Or  did  he  think,  peradvent- 
iire,  he  was  destroying  some  evil  spirit,  or  some  bii'd  or  beast?  If  he 
did  not  know  he  was  killing  a  human  being — if  he  did  not  know  wluit 
he  was  doing  at  all — if  he  was  so  idiotic  as  to  be  utterty  and  entirely 
ignorant  of  what  he  was  about,  he  was  no  more  subject  to  punishment, 
no  more  accountable  to  a  human  tribunal,  than  an  animal."  In  the  same 
debate  (p.  721)  Lord  Lyndliurst  instanced  as  an  example  of  this  conq;)lete 
illusion  a  ease  taken  from  the  Scotch  reports,  of  a  man  tried  for  the 
murder  of  another  by  shooting  him  while  he  was  goinp-  across  a  moor. 


MEy^JL   llKSrONSiniLITY  IN  CL'IMIAJL    CASES.  227 

It  had  been  cLiimed  tliat  tlio  prisoner  labored  under  the  dcbision  tliat 
the  man  he  shot  was  an  evil  spirit  whom  the  Ahnighty  had  commanded 
liini  to  kill.  As  to  the  second  part  of  the  canon,  that  relating  to  the 
•conseionsness  of  tlie  difference  between  riji^ht  and  wrong-,  good  and  evil, 
the  judges  in  their  instructions  would  seem  to  reefer  the  (juestion  of  re- 
sponsibility to  the  consciousness  of  the  individual  in  respect  to  abstract 
right  and  wrong;  the  right  and  wrong  of  the  pai-ticular  case;  the  right 
iind  wrong  of  the  moral  law,  the  law  of  ( Jod,  or  the  enactments  of  posi- 
tive law,  the  law  of  the  land.  B}^  some  it  has  been  (iontentled  that  the 
•canon  refei's  to  the  moral  law  alone  {iSfafe  vs.  Spencer,  supra) ;  by 
others  as  strenuously,  to  the  enactments  of  positive  lav^,  the  fact  of  pun- 
ishability. This  latter  view  appeals  most  strongly  to  those  who  seek  in 
the  law  a  precision  perhaps  unattainable  ;  for  in  relation  to  the  conscious- 
ness, the  existence  of  a  fact  as  that  of  i)unishment  is,  as  it  were,  a  fixed 
point,  when  compared  with  the  fluctuating  conceptions  of  moral  right 
and  wrong  that  may  be  entertained  by  individuals.  "  He  [Lord  Broug- 
ham] knew  the  learned  judges  used  the  phrase  with  reference  to  the 
<}ommands  of  the  law.  They  could  only  know  one  kind  of  right  and 
wi'ong ;  the  right  is  when  you  act  according  to  law,  and  the  wrong  is 
when  you  break  it.  .  .  .  Distinguishing  right  from  wrong  meant  a 
knowledge  tliat  the  act  the  person  was  about  to  commit  was  punishable 
by  the  law."  (Hansard's  Debates,  vol.  Ixvii.,  p.  732.)  Baron  Bramwell 
strenuously  maintained  similar  view^s  before  the  select  committee  of  the 
House  of  Commons  upon  the  Homicide  Law  Amendment  Act  (Special 
Eep(u-t  of  Select  Committee,  vol.  ix.,  p.  26,  1874):  "A  crazy  fellow 
knows  it  is  forbidden  by  law  to  knock  out  my  brains,  but  has  a  notion 
it  is  morally  right  because  I  once  tried  a  Fenian.  Is  it  to  be  no  crime? 
.  .  .  He  [Mr.  Stephen,  the  author  of  the  proposed  act]  says,  '  I  presume 
the  notion  arises  from  a  disease  affecting  the  crazy  fellow's  mind,  where- 
by he  is  prevented  from  knowing  that  it  is  morally  wrong  to  kill  a 
judge  who  tried  a  Fenian;  if  not,  the  section  does  not  apply;  but 
making  that  assumption,  I  say  distinctly  no  crime  has  been  committed, 
because  one  of  the  conditions  which  law  assumes  in  dealing  with  men 
is,  that  their  moral  feelings  are  on  its  side,  to  the  extent,  at  all  events,  of 
understanding  that  acts  of  atrocious  wickedness  are  atrociously  wicked, 
and  that  a})art  from  the  law  they  ought  not  to  do  them  ;  and  this  element 
is  wanting  in  the  case  supposed.'  He  says  further,  '■  I  do  not  believe  in  the 
possibility  of  neglecting  this  consideration  in  practice,  as  the  following 
€ase  will  show.'  ...  It  is  the  case  of  a  man  [James  Hadfield]  who  sup- 
posed that  if  he  could  lie  put  to  death  he  wt)uld  save  the  world,  and  then 
he  murders  somebody,  to  get  hanged  in  order  to  save  the  world.  Mr. 
Stephen  says,  'Would  Baron  Bramwell  say  that  he  ought  to  be  hung? ' 
(I  beg  to  say  that  is  not  the  question.  The  question  is,  Whni  rule  are  you 
to  lay  down ;  are  you  to  lay  down  a  rule  which  would  exclude  his  being- 
hung  f)  HarcUy,  I  think;  but  if  not,  wdiy  notf  'He  not  only  knows 
what  he  is  doing,  and  that  it  is  forbidden  by  law,  but  the  fact  that  it  is 
so  forbidden  is  the  very  motive  which  makes  him  do  it.  .  .  .  The  man 
is  under  a  monstrous  delusion  which  prevents  him  from  attending  to  or 
judging  of  the  moral  character  of  what  he  does,  and  ought  no  niore  to 
be  punished  than  a  dreamer  is  blamed  for  what  he  does  in  his  dreams.' 
I  have  put  in  answer  to  that,  '  I  would  not  have  a  law  to  except  this  case. 
which  would  necessarily  except  others  that  ought  not  to  be  excepted.' 


228  ^  SYSTEM  OF  LEGAL  MEDICINE. 

The  question  is,  what  rule  you  ought  to  lay  down.  In  the  particular 
case  he  cites,  probably  you  would  let  the  man  oif  being  hung,  but  that 
he  ought  to  be  held  guilty  of  murder  I  have  no  doubt ;  whether  I  would 
hang  him  is  another  matter.  And  when  Mr.  Stephen  says,  '  One  of  the 
conditions  which  law  assumes  in  deahng  with  men  is,  that  their  moral 
feelings  are  on  its  side,  to  the  extent,  at  all  events,  of  understanding  that 
acts  of  atrocious  wickedness  are  atrociously  wicked,  and  that  apart  from 
the  law  they  ought  not  to  do  them,'  I  deny  that  to  my  mind  the  law  has 
anything  to  do  with  it ;  but  it  simply  tends  to  terrify  the  man,  to  threaten 
him;  it  cares  not  what  his  views  are  on  the  sul)ject,  but  says,  'That  is  a 
thing  you  should  not  do.'  I  do  not  quite  understand  that  passage,  and 
it  would  be  very  odd  if  it  were  true  of  moral  and  not  of  religious  feel- 
ings ;  which  religious  feelings  have  continually  driven  people  into  the 
commission  of  crime.  .  .  .  What  you  want  to  do  is  to  frighten  people,, 
to  terrify  them,  and  the  way  to  try  who  ought  to  l^e  punished,  to  my 
■mind,  is  to  try  who  ought  to  he  threatened  with  punishment ;  .  .  .if  you 
can  find  out  what  man's  mind  is  accessible  to  the  influence  of  fear,  you 
can  find  out  the  man  you  should  punish,  because  those  whom  j^ou  threaten 
you  ought  to  punish,  that  it  may  not  be  h'ntum  fulmen.  You  ought  ta 
threaten  every  man  sensible  to  the  effect  of  a  threat,  and  if  this  crazy 
fellow  knows  that  what  he  thinks  a  virtuous  or  moral  action  is  one  which 
would  ca.use  him  to  be  hung,  I  shall  feel  much  more  safety  after  having 
tried  Fenians  than  I  could  otherwise  feel." 

Sir  James  Mansfield  instructed  the  jur}^  in  Bellingham's  Case  (supra) 
that  there  was  a  third  species  of  insanity  in  which  the  patient  fancied  the 
existence  of  injury  and  sought  an  opportunity  of  gi'atifying  revenge  by 
some  hostile  act.  If  such  a  person  were  capable  in  other  respects  of  distin- 
guishing right  from  ^n'oiig,  there  was  no  excuse  for  any  act  of  atrocity 
which  he  might  commit  under  this  description  of  derangement.  This  doc- 
trine placed  obviously  the  criterion  in  the  knowledge  of  right  and  "WTong, 
good  and  evil,  in  the  abstract.  The  fallac}^  of  this  view  became  evident 
when  the  case  of  James  Hadfield  (supra)  had  shown  the  necessarj^  consid- 
eration of  delusion  as  an  element  in  the  criterion  of  responsibility.  '''  Few 
ihen,"  says  Alison,  "  are  mad  about  others  or  things,  in  general ;  many 
about  themselves.  Although,  therefore,  the  j^anel  [prisoner  or  accused] 
understands  perfectly  the  distinction  of  right  and  ^^a'ong•,  yet  if  he 
labors,  as  is  generally  the  case,  under  an  illusion  and  deception  as  to  his 
own  particular  case,  and  is  thereb}^  disabled  from  appl3'ing  it  coirectly  to 
his  own  conduct,  he  is  in  that  state  of  mental  alienation  wliich  renders 
him  not  criminally  answerable  for  his  actions."  (Alison's  Principles  of  the 
Criminal  Laws  of  Scotland,  chap,  xxxv.,  sec.  i. ;  Hume's  Commentaries  on 
the  Law  of  Scotland,  vol.  i.,  chap,  i.)  Of  these  questions  an  authoritative 
resolution  is  found  in  the  answers  given  by  the  judges  of  England  (with 
the  excep)tion  of  Mi-.  Justice  Maule)  to  the  questions  put  them  by  the 
House  of  Lords  in  consequence  of  the  acquittal  of  Daniel  McNaghten, 
indicted  for  the  murder  of  Mr.  Drummond,  secretary  of  Sir  Robert  Peel. 
(10  01.  &  F.  200.)  These  judges,  speaking  through  the  Lord  Chief -Jus- 
tice Tindal,  gave  the  following  answers  :  "  The  first  question  proposed  by 
your  lordships  is  this:  'What  is  the  law  respecting  alleged  crimes  com- 
mitted by  persons  afflicted  mth  insane  delusion  in  respect  of  one  or  more 
particular  subjects  or  persons ;  as,  for  instance,  where  at  the  time  of  the 
commission  of  the  alleged  crime  the  accused  knew  he  was  acting  contrary 


MKNTAL   RESrOXSIIirLTTY  IN  CRIMINAL    CASUS.  220 

to  law,  l)iit  (lid  the  act  eoinplained  of  with  a  view,  under  the  influeiiec  of 
insane  delusion,  of  redressing-  or  revenging'  some  supposed  grievance  or 
injury,  or  of  producing'  soin(!  su})pos('(l  public,  iM-nefitif'  In  answer  to 
which  (piestion,  assuniing  that  your  loi-dsliips'  incjuiries  are  confined  to 
those  persons  who  labor  under  such  2)artial  delusions  only  and  are  not  in 
other  respects  insane,  we  are  of  opinion  that,  uotwithstantling  the  party 
accused  did  the  act  complained  of  with  a  view,  under  the  influence  of 
insane  delusion,  of  redressing  or  revenging  some  supposed  grievance  or 
injury,  or  of  producing  some  pul)lic  benefit,  he  is  nevertheless  punishable 
according  to  the  nature  of  the  crime  committed,  if  he  knew  at  the  time 
of  committing  such  crime  that  he  was  acting  contrary  to  the  law;  by 
which  expression  wo  understand  your  lordships  to  mean  the  law  of  the 
land.  Your  lordships  are  pleased  to  inquire  of  us  sectondly,  'What  are 
the  proi)er  (Questions  to  be  submitted  to  the  jury  where  a  person,  alleged 
to  be  afflicted  with  insane  delusion  respecting  one  or  more  particular 
subjects  or  persons,  is  charged  with  the  commission  of  a  crime  (murder, 
for  example),  and  insanity  is  set  up  as  a  defense?'  And  thirdly,  'lu 
what  terms  ought  the  question  to  l)e  left  to  the  jury  as  to  the  prisoner's 
state  of  mind  at  the  time  when  the  act  was  committed  f '  And  as  these 
two  questions  appear  to  us  to  be  more  conveniently  answered  together,, 
we  have  to  submit  our  opinion  to  be,  that  the  jurors  ought  to  be  told  in 
all  cases  that  every  man  is  to  be  presumed  to  be  sane  and  to  possess  a 
sufficient  degree  of  reason  to  be  responsible  for  his  crimes,  until  the  con- 
trary be  proved  to  their  satisfaction ;  and  that  to  establish  a  defense  on 
the  ground  of  insanity  it  must  be  clearly  proved  that,  at  the  tune  of  the 
committing  of  the  act,  the  party  accused  was  laboring  under  such  a  de- 
fect of  reason,  from  disease  of  the  mind,  as  not  to  know  the  nature  and 
quality  of  the  act  he  was  doing;  or,  if  he  did  know  it,  that  he  did  not 
know  he  was  doing  what  Avas  wrong.  The  mode  of  putting  the  latter  part 
of  the  question  to  the  jury  on  these  occasions  has  generally  been,  whether 
the  accused  at  the  time  of  doing  the  act  knew  the  difference  between  right 
and  wrong ;  which  mode,  though  rarely,  if  ever,  leading  to  any  mistake 
on  the  part  of  the  jiiry,  is  not,  as  we  conceive,  so  accurate  when  put  gen- 
erally and  in  the  abstract  as  when  put  with  reference  to  the  party's 
knowledge  of  i-ight  and  wi'ong  in  respect  to  the  very  act  with  which  he 
is  charged.  If  the  question  were  to  be  put  as  to  the  knowledge  of  the 
accused  solely  and  exclusively  Avith  reference  to  the  law  of  the  land,  it 
might  tend  to  confound  the  jur}^,  by  inducing  them  to  believe  that  an 
actual  knowledge  of  the  law  of  the  land  was  essential  in  order  to  lead  to 
a  conviction ;  whereas  the  law  is  administered  upon  the  principle  that 
everj^  one  nuist  be  taken  conclusively  to  know  it,  without  proof  that  he 
does  know  it.  If  the  accused  was  conscious  that  the  act  was  one  which 
he  ought  not  to  do,  and  if  that  act  was  at  the  same  time  contrai-y  to  the 
law  of  the  land,  he  is  punishable ;  and  the  usual  course,  therefore,  has 
b(K'n  to  leave  the  (|uestioii  to  the  jury,  whether  the  party  accused  had  a 
sufficient  degree  of  reason  to  know  that  he  was  doing  an  act  that  was 
wrong;  and  this  course  we  think  is  correct,  accompanied  Avith  such  ob- 
servations and  explanations  as  the  circumstances  of  each  particular  case 
may  require.  The  fourth  question  which  your  lordships  have  j)roposed 
to  us  is  this:  'If  a  person  under  an  insane  delusion  as  to  existing  facts 
connnits  an  oifense  in  consequence  thereof,  is  he  thereby  excused  ? '  To 
which  question  the  answer  must,  of  course,  depend  on  the  nature  of  the 


230  ^   SYSTEM  OF  LEGAL  MEDICINE. 

delusion ;  but,  making  tlie  same  assumption  as  we  did  before,  namely, 
tliat  lie  labors  under  sucli  partial  delusion  only,  and  is  not  in  other  re- 
spects insane,  we  think  he  must  be  considered  in  the  same  situation  as 
to  responsibility  as  if  the  facts  with  respect  to  which  the  delusion  exists 
were  real.  For  example,  if,  under  the  influence  of  his  delusion,  he  sup- 
poses another  man  to  be  in  the  act  of  attempting  to  take  away  his  life, 
and  he  kills  that  hian,  as  he  supposes,  in  self-defense,  he  would  be  exempt 
from  punishment.  If  his  delusion  was  that  the  deceased  had  inflicted  a 
serioiis  injury  to  his  character  and  fortune  and  he  killed  him  in  revenge 
for  such  supposed  injury,  he  would  be  liable  to  punishment." 

The  questions  put  to  the  judges  were  general  in  their  terms,  ha\ing 
reference  to  the  facts  of  no  particular  case,  and  Mr.  Justice  Maide  ex- 
pressed a  fear  (p.  204)  that  the  answers  might,  from  their  necessary  gen- 
erahty,  prove  an  embarrassment  in  the  administration  of  justice.  There 
was  also  a  cpiestion  whether  the  lords  had  a  constitutional  right  to  put 
them  under  existing  circumstances.  Be  this  as  it  may,  they  are  regarded 
as  an  authoritative  exposition  of  the  law  by  the  com-ts  of 

THE   UXITED    STATES. 

U.  8.  vs.  Solmes,  1  Chf.  98 ;  U.  S.  vs.  Xiclwlas  ScJiuJfz,  6  MacL.  121 ; 
U.  8.  vs.  McGIue,  1  Curt.  1 ;  as  well  as  by  the  coiu'ts  of  the  following  of 
the  United  States  of  America : 

ARKANSAS. 

Casaf  vs.  State,  40  Ai-k.  511. 

CALIFORNIA. 

Peo2)le  vs.  Holson,  17  Cal.  424 ;  Peo2}Je  vs.  Coffman,  24  Cal.  230 ;  People 
vs.  McDonnell,  47  Cal.  134 ;  People  vs.  Ferris,  55  Cal.  588 ;  People  vs.  Pico, 
62  Cal.  50;  People  vs.  Hoin,  62  Cal.  120;  People  vs.  Blalie,  65  Cal.  275. 

DELAWARE. 

State  YB.Windsor,  5  Harr.  (Del.)  512. 

GEORGIA. 

Poherts  vs.  State,  3  Geo.  310 ;  Loyd  vs.  State,  45  Greo.  57 ;  BrinJcley  vs. 
State,  58  Geo.  296. 

IDAHO. 

People  vs.  Walter,  1  Ida.  386. 

KANSAS. 

State  vs.  Malm,  25  Kan.  182. 

MAINE. 

State  vs.  Lawrence,  57  Mai.  574. 

JIASSACHUSETTS. 

Commonwealth  vs.  Rogers,  Jr.,  7  Mete.  500. 


MENTAL   nESPOXSinilATy  IX  CniMIXJL    CASES.  231 

lyilNNESOTA. 

State  vs.  Shippey,  10  Minn.  223 ;  State  vs.  Gut,  13  Minn.  341. 

MSSOURI. 

State  vs.  Ruting,  21  Mo.  4G4 ;  State  vs.  Redemeier,  71  Mo.  173 ;  State 
vs.  i;r/>,  74  Mo.  199 ;  State  vs.  Kotovshy,  74  Mo.  247. 

NEBRASIvA. 

Wright  vs.  People,  4  Neb.  407  ;  Ifair^  vs.  People,  11  Neb.  537 ;  Bar^  vs. 
mate,  14  Neb.  573. 

NEVADA. 

State  vs.  ie?m,  20  Nev.  333. 

NEW   JERSEY. 

/8'tofe  vs.  Spencer,  1  Zab.  196. 

NEW  YORK. 

Freeman  vs.  People,  4  Den.  9  ;  TT^/JZ/.s  vs.  People,  32  N.  Y.  715 ;  Flana- 
gan vs.  People,  52  N.  Y.  467  ;  Moett  vs.  Peojile  of  the  State  of  Xew  Yorl;  85 
N.  Y.  3735  Walker  vs.  Peojjle  of  the  State  of  Keiv  York,  88  N.  Y.  81. 

NORTH   CAROLINA. 

State  vs.  Brandon,  8  Jones  (L.)  463 ;  State  vs.  Raijtvard,  Pliil.  N.  C.  376. 

OHIO. 

Clark  vs.  The  State,  12  O.  483. 

OREGON. 

State  of  Oregon  vs.  Murray,  11  Or.  413. 

TENNESSEE, 

Rove  vs.  T/?^  /S'frtff,  3  Heisk.  348. 

TEXAS. 

Thomas  vs.  State,  40  Tex.  60. 

THE   DISTRICT   OF   COLOIBIA. 

U.  S.  vs.  Guiteau,  1  Mackey,  498  ;  U.  S.  vs.  Xee,  4  Mackey,  489 ;  Z7.  S.  vs. 
€7rtr/.-f,  2  Cranch,  D.  C.  158. 

Of  an  authority  almost  equal  to  these  answers  is  the  famous  charg3 
of  Cliief-Justice  Shaw  in  the  case  of  Commonwealth  vs.  Rogers  (supra), 
which  has  been  repeated  almost  verliatim  in  the  instructions  given  to 
juries  by  the  judges  in  man\'  States  of  the  American  Union. 

The  law,  in  its  inquiry  as  to  the  fact  of  the  existence  of  the  capacity 
to  know  right  from  wrong,  good  from  evil,  has  given,  as  it  were,  a  legal 


232  A   SYSTEM  OF  LEGAL  MEDICINE. 

recognition  to  certain  facts  which,  as  the  indicia  of  the  existence  of  this 
capacity,  it  regards  as  leading  symptoms  in  the  diagnosis  of  criminal 
responsibility.  As  an  all-controlling  principle  may  be  considered  the 
dogma  (which  is  without  exception)  that  the  fact  of  insanity  cannot  be 
inferred  intrinsically  from  the  nature  of  the  act  itself,  but  must  be 
proved  extrinsically,  although  its  atrocious  character  may  support  such 
extrinsic  proof  of  the  fact  of  insanity.  {Laros  vs.  Commonwealth,  84  Pa, 
St.  200.) 

1.  Evidences  of  Design  and  of  the  Adaptation  of  Means  to  an  End. 

In  the  early  cases  great  stress  is  laid  upon  any  fact  or  facts  tending- 
to  show  that  the  accused  had  a  steady  and  resolute  design  and  used  all 
proper  means  to  effect  it.  (Trial  of  Edward  Arnold,  supra ;  Trial  of  Earl 
Ferrers,  19  How.  St.  Tr.  886 ;  Trial  of  James  Hadfield,  supra.) 

At  that  time,  when  the  possession  of  any  memory  and  understanding 
of  any  of  the  mind's  essential  constituents  argued  the  existence  of  the 
capacity  to  know  right  from  wrong,  good  from  evil,  and  consequently 
that  of  responsibility,  it  was  considered  an  obvious  consequence  that  the 
capacity  to  form  a  design,  one  of  the  most  ordinary  proofs  of  the  pos- 
session of  reason,  should  be  considered  a  decisive  circumstance.  At  the 
present  day  this  same  capacit}!'  is  considered  a  controlling  element  in  the 
diagnosis  of  responsibility.  In  the  case  of  The  People  vs.  Henry  Camel, 
the  defense  being  insanity,  Mr.  Justice  Edmonds  instructed  the  jury  that 
the  capacity  to  form  an  intention,  and  of  devising  the  means  of  execut- 
ing it,  would  warrant  a  conviction.  (2  Edm.  Sel.  Ca.  200.)  The  New 
York  Court  of  Appeals  held  in  the  recent  case  of  The  People  vs.  Earlier 
(115  N.  Y.  475)  that  "  the  facts  relied  upon  by  the  prosecution  to  show 
the  adaptation  of  means  to  ends  ,  .  .  are  factors  of  importance  upon 
the  question  of  the  defendant's  legal  responsibility." 

Although  abstract  and  a  pmori  reasoning  might  lead  one  naturally 
to  infer  that  the  capacity  to  form  a  design,  and  the  use  of  means  suited 
to  its  accomplishment,  would  conclusively  prove  the  existence  of  a  mind 
"undisturbed,  or  one  sufficiently  so  as  to  impose  responsibility,  a  closer 
observation  of  the  characteristics  of  insanity  has  had  a  tendency  to  dis- 
credit the  so-called  "  method  in  madness."  It  has  been  shown  that  cun- 
ning and  contrivance  are  of  the  qualities  least  frequently  affected  by  in- 
sanity, and  it  is  considered,  among  the  Continental  jurists  at  least,  that 
the  test  has  little  diagnostic  value.  In  their  opinion  the  examination  of 
the  systematic  planning  of  a  deed  can  only  be  valuable  when  it  tends  to 
indicate  a  condition  of  irresponsibility — "when  these  plans  and  prep- 
arations themselves  evince  the  stamp  of  a  confused  intellect,  and  betray 
the  hazy  consciousness,  the  mental  darkness  in  which  the  culprit  was  in- 
volved." (Casper's  Handhooh  of  Forensic  Medicine,  vol.  iv.,  part  vi.,  chap, 
i.,  sec.  62  ;  "  Review  of  Mittermaier  on  the  Excuse  of  Insanity,"  American 
Jurist,  vol.  xxii.,  p.  312.) 

2.  The  Appreciation  of  the  Nature  of  the  Act  and  its  Consequences. 

From  the  earliest  times  the  fact  of  responsibility  has  been  inferred 
from  any  circumstance  that  might  evidence  the  possession  of  the  above 
capacity.    Of  this  tb^'  ^-"o  cases  cited  by  Hale  are  examples — the  one^  "  an. 


MENTAL   llESroysiniLITT  IN  CJinilNAL    CAHES.  233 

infaut  within  ag'e  that  liad  killed  his  companion  and  hid  himself  was 
presently  hang-ed,  for  it  appeared  by  his  hiding-  he  could  discern  Ijctween 
go(jd  and  evil ;  "  the  other,  "  an  infant  of  the  age  of  nine  years  killed  an 
infant  of  the  like  age ;  he  confessed  the  felony,  and  upon  examinati(jn  it 
was  found  he  hid  the  blood  and  the  body;  the  justices  held  he  ought  to 
be  hanged."  (1  Hale,  P.  C,  2G,  27.)  In  the  trial  of  Lord  Ferrers  (supra)  the 
ease  of  the  Crown,  as  set  forth  by  the  solicitor-general,  was  mainh-  an  appli- 
cation of  this  and  the  j)receding  criterion.  As  evidences  of  Lord  Ferrers's 
knowledge  of  the  consequences  of  his  act,  the  solicitor- genei*al  emphasized 
the  sending  for  a  surgeon,  and  his  inquiry  whether  the  steward  Johnson, 
whom  he  had  shot,  would  live  or  die ;  his  statement  to  Johnson's  daugh- 
ter that  he  feared  a  pr<\<ecutiou,  with  the  addition  that  if  she  would  not 
prosecute  him  he  would  maintain  her  and  her  family ;  his  expression  of 
fears  as  to  being  arrested  for  his  act.  This  same  appreciation  may  be 
manifested  in  many  ways,  such  as  by  the  expression  of  the  determina- 
tion to  be  hanged  {Regina  vs.  Burton,  3  F.  &  F.  772),  to  be  "  electrocuted" 
(People  vs.  Taylor,  138  N.  Y.  399) ;  but  the  most  common  are  the  hiding 
or  flight  of  the  accused  and  the  conceahnent  of  the  corpus  delicti.  The 
defendant  in  the  case  of  The  People  vs.  Barher  (supra)  was  indicted  for 
the  murder  of  one  Ann  Mason,  the  defense  being  that  the  act  had  been 
committed  dming  an  epileptic  paroxysm.  The  accused,  who  had  been 
on  terms  of  intimacy  with  the  Masons,  au  elderly  couple,  had,  while  on. 
a  visit  to  them,  without  any  cause  or  apparent  motive,  assaulted  them 
both  with  a  billet  of  wood  which  he  had  taken  from  a  woodpile  on  the 
premises.  He  then  set  fire  to  the  house,  in  the  ruins  of  which  were  found 
the  remains  of  the  woman  Mason.  The  looking  out  of  the  door  by  the 
accused  before  lea\4ng  the  house ;  his  occasional  answers  to  questions 
put  him  by  Mason  during  the  perpetration  of  the  deed ;  the  absence  of 
blood  on  his  clothing,  although  Mason  bled  freely ;  the  discovery  of  the 
footprints  of  a  Xo.  7  shoe  in  the  snow,  two  days  after  the  event,  leading 
in  a  zigzag  dii-ectiou  away  from  the  house,  and  occasionally  turning  as  2 
the  wearer  were  looking  at  the  fii*e — were  ui-ged  as  facts  tending  to  sup- 
port the  theory  of  a  knowledge  of  the  natiu-e  of  the  act,  and  a  desire  to 
escape.  (The  Barber  Case,  American  Journal  of  Insanity,  vol.  xlv.,  p.  360.) 
The  New  York  Court  of  Appeals,  in  their  reversal  of  the  judgment  of 
con\lction,  held  that  upou  a  new  trial  the  above  fact«  were  factors  of 
importance  upon  the  question  of  the  defendant's  respousibihty.  On  the 
other  hand,  presumptions  favoral)le  to  the  accused  have  been  drawn  from 
the  apparent  want  of  this  capacit}-  of  appreciation,  such  as  the  fact  of 
the  deed  ha\'ing  been  committed  under  circumstances  which  rendered 
detection  almost  inevitable.  [Rerjina  vs.  Layton,  supra.)  This  criterion 
cannot,  however,  be  taken  as  decisive.  Inferences  as  to  irresponsibility 
from  the  evident  want  of  appreciation  of  the  nature  of  the  act  and  its 
consequencies  can  be  draA\ni  with  greater  certainty  than  the  fact  of  re- 
sponsibility from  the  possession  of  this  appreciation,  for  it  seems  to  have 
been  had  by  many  lunatics  of  unquestioned  irresponsil)ility.  The  artist 
Dadd,  who  murdered  his  father  at  Cobliam  Park,  England,  fled  to  France 
after  the  commission  of  the  deed.  Of  this  person's  insanity,  which  had 
manifested  itself  some  time  before  the  act,  there  could  be  no  doulit. 
[Annual  Reyister  of  August  31,  1843.)  The  books  contain  many  smiilar 
instances. 


234  ^   SYSTEM  OF  LEGAL  MEDICINE. 

3.  The  Uxistence  or  Absence  of  Motive. 

Evidence  of  the  want  of  motive  on  the  part  of  the  accused  for  the 
perpetration  of  the  deed  is  considered  to  be  a  strong  corroboration  of  the 
fact  of  irresponsibility.  "  I  do  not  say/'  says  Chief -Justice  Hornblower 
{IStatevs.  Bpencer,  supra),  "that  this  absence  of  apparent  motive  invari- 
fihlij  exists  in  cases  of  liomicide  and  other  atrocious  acts  committed  by 
insane  persons,  but  I  say  tliat  it  is  yeneralhj  the  case.  Hence,  if  we  wit- 
ness the  perpetration  of  such  an  act  without  any  apparent  motive  or 
object,  but  against  every  motive  which  would  api3ear  to  be  naturally  in- 
fluential with  the  person  committing  it,  we  at  once  awake  to  the  inquiiy 
whether  he  was  in  his  sound  mind,  and  if  we  can  lay  hold  of  any  sufficient 
evidence  that  he  was  not  so,  this  absence  of  apparent  motive  confirms  us 
in  the  belief  that  he  was  insane."  {.Regina  vs.  Layton,  supra;  People  vs. 
^flr&p>-,  supra ;  Conimonu^eaUh  y&.  Buccieri,  sixpva,.)  In  the  application  of 
this  criterion  a  distinction  has  been  drawn  between  mere  absence  of  evi- 
dence of  the  existence  of  motive  and  affirmative  evidence  of  its  non-exist- 
ence, the  latter  only  being  considered  to  be  a  factor  in  the  question  as  to 
the  fact  of  responsibility.  [Regina  vs.  Law,  2  F.  &  F.  836,  note  a.)  Nor 
can  an  inference  as  to  the  existence  of  an  insane  irresistible  impulse  be 
made  per  viam  exclusionis  from  the  concmTcnce  of  the  apparent  absence  of 
motive  and  the  atrocity  of  the  deed,  for  according  to  Baron  Rolfe  [Regina 
vs.  StoA'es,  3  C.  &  K.  18o)  it  is  considered  dangerous  ground  to  take  to  say 
that  a  man  must  be  insane  because  men  fail  to  discern  the  motive  of  his 
act ;  and  according  to  Baron  Bramwell  [Regina  vs.  Haynes,  1  F.  &  F.  666) 
motives  exist  uukno^Ti  and  innumerable  which  might  prompt  the  act. 

Any  evidence  as  to  the  non-existence  of  motive  has  been  held  imma- 
terial when  a  knowledge  of  the  natm-e  of  the  act  is  coupled  with  evident 
intention  to  do  it.  [Regina  vs.  Dixon,  11  Cox,  C.  C.  341.)  It  has  been 
determined  that  evidence  of  the  absence  of  motive  is  an  essential  factor 
in  considering  the  responsibility  of  epileptics  [People  vs.  Barber,  supra) ; 
but  on  the  part  of  medical  science  it  has  been  maintained  that  evidence 
of  the  existence  of  such  motive  is  not  decisive.  "These  patients,"  it 
is  said,  "  are  controlled  in  the  midst  of  their  passions  by  an  appreciable 
motive,  which  has  for  them  a  reality ;  but  we  should  ask  ourselves  if  in 
a  state  of  sanity  such  a  motive  would  arise,  and,  above  all,  if  it  would  be 
predominant  enough  to  control  reason.  Thus  the  motive  and  premedita- 
tion, which  seem  under  such  circumstances  to  have  dictated  the  criminal 
act,  are  insufficient  to  establish  peremptorily  the  integrity  of  free-will, 
and  consequently  the  existence  of  guilt."  ("Criminal  Responsibility  of 
Epileptics  as  Illustrated  by  the  Case  of  Da^id  Montgomery,"  by  M.  G. 
Echeverria,  American  Jotirnal  of  Insanity,  vol.  xxix.,  p.  341.) 

4.  The  Acting  upon  Existing  Facts,  the  Rum  an  Passion  being  Directed  to  its 

Proper  Object. 

The  consideration  of  this  criterion  forms  part  of  the  subject  of 

DELUSIONS. 

From  the  fact  of  the  essential  characteristic  of  partial  insanity  being 
its  limitation  to  one  or  more  points,  the  most  ordinary  evidence  of  which 


MESTAL   nESrOX/^IIilLITY  IN  CRIMINAL    CASES.  235 

is  tlie  existence  of  one  or  more  delusions,  the  acquittal  of  James  Had- 
field  (sui)ra)  gave  a  legal  recognition  to  the  theory  that  delusion,  wlien 
there  is  no  frenzy  or  raving  madness,  is  of  the  very  essence  of  insanity. 
In  his  memorable  defense  Erskine  maintained  that  the  premises  from 
which  such  insane  persons  reason,  when  witljin  the  range  of  the  malady, 
were  uniformly  false,  not  from  any  defect  of  knowledge  or  judgment, 
but  because  a  delusive  image,  the  inseparable  companion  of  real  insanity, 
was  thrust  upon  the  subjugated  understanding,  incapable  of  resistance 
because  unconscious  of  attack.  In  his  opinion,  when  delusion  could  not 
be  predicated  of  a  man  standing  for  life  or  death  for  a  crime,  he  ought 
not  to  be  acquitted.  These  views,  which  are  not  consonant  with  the  sci- 
ence of  the  day  (''  The  Legal  Doctrine  of  ResponsibiUty  in  Cases  of  Insan- 
ity Connected  with  Alleged  Criminal  Acts,"  by  Forbes  Winslow,  1  Jurid- 
ical Sociefi/  Papers,  595),  reflected  the  medical  ideas  of  the  time,  and 
above  all  the  metaphysical  speculations  of  Locke,  the  predominant  philo- 
sophical authority,  who  thus  distinguished  between  idiocy  and  insanity : 
"  In  fine,  the  defect  in  naturals  seems  to  proceed  from  want  of  quickness, 
activity,  and  motion  in  the  intellectual  faculties,  whereby  they  are  de- 
prived of  reason ;  whereas  madmen,  on  the  other  side,  seem  to  suffer  by 
the  other  extreme,  for  they  do  not  appear  to  me  to  have  lost  the  faculty 
of  reasoning,  but,  having  joined  together  some  ideas  very  ■\va"ongly,  they 
mistake  them  for  truths,  and  they  err  as  men  do  that  argue  right  from 
wi-ong  principles,  for  by  the  violence  of  theii*  imaginations,  having  taken 
their  fancies  for  realities,  they  make  right  deductions  from  them.  Thus 
you  shall  fijid  a  distracted  man  fancying  himself  a  king,  with  a  right  in- 
ference requiring  suitable  attendance,  respect,  obedience;  others,  who 
have  thought  themselves  made  of  glass,  have  used  the  caution  necessar}^ 
to  preserve  such  brittle  bodies.  Hence  it  comes  to  pass  that  a  man  who  is 
very  sober,  and  of  a  i-ight  understanding  in  all  other  things,  may  in  one 
particular  be  as  frantic  as  any  in  bedlam,  if,  either  by  any  sudden  very 
strong  impression  or  long  fixing  his  fancy  upon  one  sort  of  thoughts, 
incoherent  ideas  have  been  cemented  together  so  powerfully  as  to  remain 
united.  But  there  are  degrees  of  madness,  as  of  folly;  the  disorderly 
jumbling  of  ideas  together  is  in  some  more,  some  less.  In  short,  herein 
seems  to  lie  the  difference  between  idiots  and  madmen :  tliat  madmen  put 
wi'ong  ideas  together  and  so  make  wi-ong  propositions,  but  argue  and  rea- 
son right  from  them ;  but  idiots  make  very  few  or  no  propositions,  and 
reason  scarce  at  all."  [Essay  on  the  Human  Understanding,  book  ii.,  chap,  xi., 
sec.  13.)  These  views  have  had  a  predominant  influence  upon  the  law 
in  all  its  branches.  In  the  leading  case  of  Deiv  vs.  Clark  tO  Clarh  (3  Add. 
Eee.  79),  Sir  John  NiclioU  held  that  the  true  criterion,  the  true  test,  of 
the  absence  or  presence  of  insanity  was  the  absence  or  presence  of  delu- 
sion. At  a  recent  date.  Lord  Denman  instructed  a  jury  that  to  say  a 
man  was  irresponsible  without  positive  pi'oof  of  any  act  to  show  that  he 
was  laboring  under  soine  delusion  seemed  to  him  to  be  a  presumption 
of  knowledge  which  none  but  the  great  Creator  himself  could  possess. 
{Regitia  vs.  Smith,  "Plea  of  Insanity  in  Criminal  Cases,"  5  Journal  of 
PsychoJogical  Medicine  and  Mental  Pathologg,  p.  103.)  And  Baron  Martin, 
in  Begina  vs.  Townley  (supra),  held  that  what  the  law  meant  by  an  insane 
man  was  a  man  who  acted  under  delusions  and  supposed  a  state  of 
things  to  exist  which  did  not  exist,  and  acted  thereupon.  I"^pon  this  basis 
of  delusion  as  the  indispensable  and  essential  characteristic  of  insanity, 


'236  ^   SYSTEM  OF  LEGAL  MEDICINE. 

Erskine  formulated  a  criterion  of  responsibility  (No.  4,  supra)  which,  al- 
though it  has  had  a  certain  weight,  cannot  be  said  to  have  successfully 
withstood  the  assaults  of  adverse  criticism.  "The  principle  contended 
for  by  this  eminent  person  is  that  when  a  maniac  commits  a  crime  under 
the  influence  of  an  impression  which  is  entii'ely  ^dsionary,  and  purely  the 
hallucination  of  insanity,  he  is  not  the  object  of  punishment ;  but  that, 
though  lie  ma}^  have  shown  insanity  in  other  things,  he  is  liable  to  pun- 
ishment if  the  impression  under  which  he  acted  was  true,  and  the  human 
passion  arising  out  of  it  was  directed  to  its  proper  object.  He  illustrates 
this  principle  by  contrasting  the  case  pf  Hadfield  with  that  of  Lord  Fer- 
rers. Hadfield  had  taken  a  fancy  that  the  end  of  the  world  was  at  hand, 
and  that  the  death  of  his  Majesty  [King  George  III.]  was  in  some  way 
connected  with  important  events  which  were  about  to  take  place.  Lord 
Ferrers,  after  showing  various  indications  of  insanity,  murdered  a  man 
against  whom  he  was  known  to  harbor  deep-rooted  resentment  on  ac- 
count of  real  transactions  in  which  that  individual  had  rendered  himself 
obnoxious  to  him.  The  former,  therefore,  is  considered  as  an  example 
of  a  pure  hallucination  of  insanity ;  the  latter  as  one  of  human  passion 
founded  upon  real  events  and  directed  to  its  proper  object.  .  .  .  There 
can  be  no  doubt  of  the  first  of  his  propositions,  that  a  person  acting  under 
the  piu'e  hallucination  of  insanity  in  regard  to  impressions  which  are 
entirely  unfounded  is  not  the  object  of  punishment.  But  the  converse 
does  not  seem  to  follow,  namely,  that  the  man  becomes  an  object  of  pun- 
ishment merely  because  the  impression  was  founded  on  fact  and  because 
there  was  a  human  passion  directed  to  its  proper  object.  For  it  is 
among  the  characters  of  insanity  not  only  to  call  up  impressions  which 
are  entirely  visionary,  but  also  to  distort  and  exaggerate  those  which 
are  true,  and  to  cany  them  to  consequences  which  they  do  not  warrant 
in  the  estimation  of  a  sound  mind.  A  person,  for  instance,  who  has 
suffered  a  loss  in  business  which  does  not  affect  his  circumstances  in  any 
important  degree  may  imagine,  under  an  influence  of  hallucination,  that 
he  is  a  ruined  man  and  that  his  family  is  reduced  to  beggary.  Now  were 
a  wealthy  man  under  the  influence  of  such  hallucination  to  commit  an 
outrage  on  a  person  who  had  defrauded  him  of  a  trifling  sum,  the  case 
would  afford  the  character  mentioned  by  Erskine,  namely,  human  pas- 
sion founded  upon  real  events  and  directed  to  its  proper  object;  but  no 
one  probably  would  doubt  for  a  moment  that  the  process  was  as  much 
the  result  of  insanity  as  if  the  impression  had  been  entu-ely  visionary." 
(Abercrombie  on  The  Intellectual  Powers,  part  iii.,  sec.  iv.,  p.  2G5.)  This 
is  confirmed  by  the  affirmation  of  medical  science  that  it  is  one  of  the 
well-known  characteristics  of  insanity  for  persons  to  labor  under  delu- 
sions connected  with  and  originating  in  actual  circumstances.  ("The 
Legal  Doctrine  of  Responsibility  in  Cases  of  Insanity  Connected  with 
Alleged  Criminal  Acts,"  by  Forbes  Wiiislow,  1  Juridical  Society  Papers, 
605.)  It  would  seem,  therefore,  that  in  deciding  a  doubtful  case  a  jurj^ 
ought  not  to  be  guided  b_y  the  circumstances  of  the  ease  exclusivel_y,  but 
by  evidence  of  insanity  in  other  things  as  well.  This  seems  actually  to 
be  the  rule,  for  many  verdicts  given  b}^  juries  involve  a  practical  rejec- 
tion of  this  criterion.  The  recent  acquittal  of  John  Daley  on  the  ground 
of  insanity,  tried  in  the  city  of  Washington  for  the  murder  of  a  real- 
estate  agent  named  Kennedy,  affords  us  a  striking  instance  among  many. 
("  A  Judicial  Advance — the  Daley  Case,"  by  W.  W.  Godding,  M.D.,  Anieri- 


MENTAL   HESI'().\SIIIIL1TY  IN  CRIMINAL    CASES.  237 

can  Jonnud  of  Insanlijiy  vol.  xlv.,  p.  191,  Octohcr,  ISSft.)  Tliis  nasc  liaci 
a  twofold  aspect :  a  delusion  of  poisoning'  and  surveillance,  and  a  real 
resentment  founded  upon  existing  facts.  Daley,  an  Ii-islunan  of  about 
fift}'  years  of  age,  liad  been  a  lay  brt^tlier  in  a  Catholic  college.  While 
an  innuite  there  he  applied  for  medical  advice  to  the  clergyman  iu  charge, 
who  procured  medicine  for  him.  From  certain  circumstances  he  became 
convinced  that  the  drug  given  him  had  been  changed  by  the  ijriest  in 
order  to  poison  him  and  get  thereby  the  possession  of  his  money.  While 
the  amount  of  the  drug  taken  had  not  been  enough  to  kill  him,  it  had 
undermined  his  health,  producing  a  ''  gum  exudation  over  his  whole 
body,"  which  continued  to  the  time  of  the  murder,  and  his  life  was 
ruined  in  consequence.  On  his  leaving  the  college,  it  was  only  to  be 
shadowed  by  "  detectives  of  the  order,"  an  order,  apparently,  of  Catholic 
priests.  He  saw  them  when  he  visited  Washington  in  1878,  and  again 
in  'the  following  5^ear.  lie  made  his  home  iu  Washington  in  the  year 
1882,  and  about  that  time  comes  in  his  one  business  transaction  with  the 
deceased.  Previous  to  this  he  had  given  sums  of  money  to  his  father, 
which  had  been  expended  in  the  purchase  from  Kennedy  of  a  lot  in 
Washington.  Tlie  facts  in  regard  to  this  transaction  appear  to  have 
been :  that  the  lot  of  land  so  bought  had  again  passed  into  the  hands  of 
Kennedy,  he  holding  it  in  trust.  Daley,  !Sr.,  had  arranged  in  1882  to 
purchase  it  for  $900,  making  monthly  payments  for  the  same,  but  he 
died  before  the  completion  of  such  payments.  Kennedy  paid  the  funeral 
expenses,  charging  them  against  the  account.  When  John  Daley  de- 
manded a  settlement,  Kennedy,  after  examining  his  books,  tokl  him 
there  was  nothing  due  him.  The  lawyer  whom  Daley  subsequently  con- 
sulted advised  him  to  settle  his  claim  for  $100  if  he  could  get  it.  Ken- 
nedy finally  paid  him  $50  by  a  check,  taking  Daley's  receipt  in  full  of 
all  demands.  The  books  of  the  deceased,  produced  in  court,  showed  a 
balance  due  the  estate  at  that  time.  Kennedy  sul)sequeutly  sold  this 
same  lot  in  1886  for  more  than  the  sum  of  $5000,  as  recorded.  This 
latter  fact  probably  came  to  the  knowledge  of  Daley.  It  is  certain  that 
he  alwaj^s  believed  that  Kennedy  had  "  beat  him "  in  the  transaction, 
and,  though  he  accepted  the  check  for  $50  in  full  payment,  doubtless^ 
considered  he  had  been  defrauded  of  money  justly  due  him.  Daley, 
subsequently  laboring  under  this  delusion  as  to  his  persecution  by  the 
"  detectives  of  the  order,"  purchased  a  pistol  for  the  purpose  of  shooting 
one  Elliott,  an  apothecary  of  Washington,  whom  he  delusivel}^  imagined 
to  be  one  of  those  detectives.  This  pistol  he  sold.  At  a  later  daj^  meet- 
ing Elliott  near  the  Capitol,  he  endeavored  to  strike  him  on  the  head 
with  a  stone,  and  failing  in  his  attempt,  he  assaulted  him  with  his  fists. 
This  led  to  his  imprisonment.  Upon  his  release,  having  met  Ken- 
iiedij  in  the  streets  of  Washington,  he  plunged  a  knife  into  his  abdo- 
men. Some  time  after  his  arrest  Daley  stated  that  "he  and  Mr.  Ken- 
nedy had  had  a  dispute  over  a  real-estate  matter  and  he  had  got  even 
with  him."  The  case,  from  the  standpoint  of  the  alienist,  was  interest- 
ing but  puzzling.  The  commission  of  experts  reported  that  the  accused 
was  undoubtedly  insane,  but  that  they  were  unable  to  connect  the  homi- 
cide with  the  delusion  of  j)oisoning  and  surveillance  that  had  prompted 
the  assault  on  the  apothecary  Elliott,  nor  were  they  satisfied  that  his 
ideas  respecting  the  wrong  done  him  by  Kennedy  were  delusions  in  the 
.same  sense  as  the  above.     The  State  practically  conceded  the  fact  of  the 


238  ^   SYSTEM  OF  LEGAL  MEDICINE. 

insanity,  and  gave  the  case  to  ttie  jury  on  tlie  failnre  to  connect  the 
homicide  with  the  dehision,  its  theory  being  that  the  killing  was  founded 
upon  a  real  resentment,  the  liuman  passion  being  directed  to  its  proper 
object.  The  jury,  in  their  verdict  of  acquittal,  were  undoubtedly  led  to 
this  conclusion  by  the  evidence  of  insanity  in  other  things.  The  leading 
canon  in  the  matter  of  delusion  is,  that  the  act  should  be  the  offspring- 
of  the  delusion  itself.  "  Where  the  connection  is  doubtful,"  says  Erskine 
(Trial  of  Hadfield,  supra),  "  the  judgment  shoidd  certainly  be  most  in- 
dulgent, from  the  great  difficulty  of  diving  into  the  secret  sources  of  a 
disordered  mind ;  but  still  I  think  that,  as  a  doctrine  of  law,  the  delusion 
and  the  act  should  be  connected."  Tliis  doctrine  as  an  abstract  proposi- 
tion may  be  beyond  criticism,  for  medical  science  admits  that  "  if  the 
delusion  be  limited  to  one  or  to  a  few  closely  kindred  subjects,  and  if  it 
be  of  long  standing,  it  perhaps  is  possible  for  persons  so  afflicted  to  be 
capable  of  exercising  theii'  judgment  upon  matters  not  immediately  con- 
nected with  the  delusion."  ("AuAddi-ess  on  the  Present  Relation  of 
Insanity  to  the  Criminal  Law  of  England,"  by  W.  Orange,  M.D.,  British 
2Iedic(d  Journal  of  October  20,  1887.)  From  this  it  would  follow,  as  a 
legal  consequence,  that  the  same  rule  prevailing  in  questions  as  to  civil 
competency  should  be  apphed  to  criminal  responsibihty  {BauJiS  vs. 
Good  fellow,  L.  R.  5  Q.  B.  549) — that  the  mere  existence  of  an  insane 
delusion,  which  does  not  in  fact  influence  particular  parts  of  the  conduct 
of  the  person  afflicted  by  it,  should  have  no  effect  upon  their  legal  char- 
acter. (Stephen's  History  of  the  Criminal  Law  of  England,  chap,  xix., 
p.  162.)  The  connection,  however,  between  the  delusion  and  the  act  itself 
is  a  question  of  fact,  one  presenting  the  greatest  difficulty,  inasmuch  as 
a  connection  not  apparent  to  the  sane  mind,  nor  even  conceivable  by  it, 
may  exist  in  the  insane  one,  and  "  the  exact  bearing  of  any  delusion  can 
often  onl}^  be  ascertained  with  certainty  through  the  statements  of  the 
accused  himseK ;  and  when,  either  on  account  of  increasing  dementia,  or 
from  any  other  cause,  the  accused  is  disinclined  to  enter  into  conversa- 
tion, the  point  must  necessarily  remain  in  the  region  of  conjecture  and 
probabLlit3^"     (The  Address  of  Dr.  Orange,  supra.) 

As  illustrations.  Dr.  Orange,  in  his  address,  referred  to  above,  instanced 
several  cases.  "  In  the  case  of  the  American  surgeon  who  shot  a  man  in 
the  streets  of  London  about  four  years  ago  the  connection  between  the 
delusion  and  the  act  was  very  strikingly  marked,  although  this  connection 
was  not  made  out  at  the  trial.  The  poor  man  who  was  the  victim  was  on 
his  way  to  his  work  at  the  Lion  Brewery  between  tlu'ce  and  four  o'clock  in 
the  morning,  when  he  was  suddenly  shot  dead,  his  assailant  firing  four 
times  at  him.  His  assailant  then  gave  himself  up  quietly  to  the  i)olice, 
sapng  that  they  would  soon  find  out  he  was  quite  justified  in  what  he 
had  done.  After  he  became  an  inmate  of  Broadmoor,  he  gave  me  a 
most  vivid  account  of  the  matter  from  his  point  of  view.  He  was  under 
a  delusion  that  he  was  a  victim  of  conspiracy,  and  that  his  enemies  had 
determined  to  slowly  torture  him  to  death  by  sending  one  of  their  num- 
ber into  his  bedroom  in  the  middle  of  the  night  to  wake  him  out  of  his 
sleep.  He  provided  himself  in  consecj^uence  with  a  revolver,  which  he 
took  to  bed  with  him,  intending,  as  he  said,  to  shoot  his  persecutor  while 
actually  in  his  bedroom.  He  woke  up  with  a  start  in  the  usual  manner 
during  the  night,  and  imagined  that  he  saw  his  persecutor  at  the  foot  of 
hig  bed;  but  before  he  could  lay  his  hands  on  his  revolver  and  take  aim 


MESIAL   nESl'OySllillATy  IX  ClUMIXJL    CASES.  231) 

he  thought  he  saw  the  man  pass  out  through  the  bedroom  door.  lie 
foUowed  as  (|uiekly  as  possil)k'  and  fiineied  he  saw  the  man  on  the  stair- 
case ;  but  again  before  he  coukl  aim  the  man  liad,  as  he  th<mght,  passed 
down  to  the  next  flight.  He  still  followed,  and  again  he  thought  he 
should  have  been  sneeessful  in  shooting  his  persecutor  at  the  front  door, 
but  again  he  was  too  hite.  Still  following  the  image  that  his  delusiou 
had  conjured  up,  he  rapidly  opened  the  front  door,  and  on  the  oi)posite 
side  of  the  street  he  saw  a  man  wliom  he  immediately  shot.  In  a  case 
which  was  tried  at  Maidstone  in  1875,  and  which  obtained  some  uot«n-i- 
ety  in  consequence  of  the  strong  summing  up  of  the  judge  in  favor  of  a 
conviction,  but  in  which  the  jur}'  returned  a  verdict  that  the  man  was 
insane,  there  was  also  a  very  close  connection  between  the  man's  delu- 
sions and  his  act,  although  here  again  the  connection  was  not  clearly 
ascertained  until  after  his  trial.  The  man  had  killed  a  fellow-workman 
at  the  Chatham  Dockyard,  by  splitting  his  skidl  with  an  adze.  After  the 
man  became  an  inmate  of  Bi-oadmoor,  he  told  me  that  some  years  befoi-e 
he  had  received  the  Holy  Ghost ;  that  it  had  come  to  him  like  a  flash ; 
that  his  own  eyes  had  been  taken  out  and  other  eyes  like  balls  of  fire 
had  been  substituted.  This,  by  the  way,  was  doubtless  a  shght  epilepti- 
form seizure.  He  went  on  to  say  that  after  this  he  was  able  to  see  peo- 
ple when  they  were  not  there,  and  that  he  could  tell  whether  they  wanted 
to  '  make  him  go  down  to  the  grave.'  He  said  he  often  felt  very  ill,  as 
if  he  were  losing  his  senses,  and  that  sometimes  he  could  tell  who  it  was 
that  made  him  feel  so,  and  sometimes  he  could  not.  Upon  the  da}-  wlien 
he  killed  his  fellow-workman,  he  suddenly  felt  a  severe  pain  in  his  head. 
His  eyes  told  him  that  it  was  his  mate  who  caused  this,  and  he  struck 
him  dead.  There  was  no  doubt  whatever  that  the  man  was  quite  mad, 
and  he  is  now  steadily  going  on  toward  a  state  of  paralytic  dementia. 
...  It  would  appear  from  the  cases  just  cited,  and  from  numerous  other 
similar  cases  which  might  be  adduced  if  time  permitted,  that  the  absence 
of  direct  iwoof  of  the  connection  between  any  delusiou  and  any  insane 
act  ought  by  no  means  to  be  interpreted  as  being  equivalent  to  evidence 
that  no  such  connection  exists." 

The  criterion  contained  in  the  fourth  answer  of  the  judges  is  an  echo 
of  the  ingenicnis  speculations  of  the  jurist  Hotfbauer  {Mi'(leci)ie  legale 
relative  aux  alinu's  ef  aiix  sonrds  niuefs,  sec.  103):  "In  criminal  law  the 
dominant  idea  of  an  individual  under  the  influence  of  a  delusion  slioidd 
be  considered  as  true ;  that  is  to  say,  his  actions  should  be  judged  as  if 
he  were  actually  under  the  conditions  he  believed  himself  to  be  when 
he  committed  the  deed.  If  the  circumstances  do  not  change  in  any  re- 
spect the  nature  of  the  crime,  the  responsil)ility  and  cidpability  of  the 
accused  are  established ;  if,  on  the  other  hand,  they  diminish  or  obliter- 
ate such  culpability,  the  insane  person  cannot  be  considered  guilty.  At 
Brieg  a  soldier  killed  a  child  because  he  believed  he  saw  near  him  the 
xVlmighty,  who  commanded  him  to  do  the  killing.  In  his  report  Dr. 
Glanwitz  was  of  opinion  that  the  man  should  be  sent  to  an  insane 
asylum." 

This  criterion  gives  to  a  delusion  the  value  of  a  mistake  of  fact,  jnit- 
ting  thus  (ui  the  same  plane,  as  far  as  they  relate  to  the  consequences,  a 
delusi(ni,  the  result  of  disease,  and  a  mistake  of  fact,  the  result  of  acci- 
dent or  circumstances  like  those  narrated  in  the  case  of  William  Levett 
(4  Cro.  Car.  538),  who  killed  the  friend  of  a  servant  concealed  in  a  but- 


240  ^  SYSTEM  OF  LEGAL  MEDICINE. 

teiy,  lie  being  of  tlie  impression  tliat  she  was  a  burglar.     {Commonwealth 
vs.  M'imiemore,  1  Brewst.  357.) 

From  this  relative  j)oiut  of  view,  that  of  the  circumstances  delusively 
imagined  to  exist,  the  law  judges  the  act,  applying  to  it  the  criterion  of 
the  knowledge  of  right  and  wrong.  "  It  seems  to  us,"  says  the  Supreme 
Court  of  Mississippi,  "  only  another  method  of  stating  that  there  can  be 
no  crime  when  there  is  a  mental  incapacity  to  distinguish  between  right 
and  wrong,  for,  though  delusions  as  to  particular  matters  frequently 
exist  in  minds  which  are  perfectly  rational  upon  all  other  subjects,  yet 
if  the  delusion  be  so  fixed  and  vivid  as  to  make  the  imaginary  seem  the 
real  there  must  be  upon  that  subject  a  total  incapacity  to  distinguish 
between  right  and  wi'ong,  since,  the  entire  relation  between  the  victim  of 
the  delusion  and  its  unconscious  subject  being  mentally  perverted,  there 
can  be  no  proper  standpoint  of  right  and  wrong  in  the  diseased  mind. 
That  which  to  the  rest  of  the  world  seems  right  is  to  hnn  the  most  fla- 
grant wrong,  and  vice  versa.  If  to  his  deluded  imagination  his  best  friend, 
or  the  wife  of  his  bosom,  seems  a  relentless  foe  bent  upon  his  destruc- 
tion, he  necessarily  acts  upon  the  hallucination  which  possesses  him ;  and 
if  his  action  is  such  as  would  be  justifiable  or  proper,  if  the  reality  M^as 
as  he  supposes  it  to  be,  there  can  be  no  accountability,  because  there  has 
been  no  conscious  crime.  If  a  crazy  enthusiast  violates  the  law,  impelled 
by  madness  which  makes  him  deem  it  the  inspired  act  of  God,  he  has 
only  done  that  which  Ms  diseased  and  deluded  imagination  taught  hiin 
was  right ;  and  if  the  act  Avould  be  proper  in  one  so  divinely  inspired, 
and  was  the  du-ect  and  necessary  consequence  of  the  delusion,  there  can 
be  no  punishment,  because,  however  rational  on  other  subjects,  he  was 
on  that  subject  incapable  of  having  a  criminal  intent."  {Cunningham  vs. 
State,  56  Miss.  270.)  The  same  criterion  finds  a  shorter  but  simQar  ex- 
pression :  "  A  simple  and  sound  rule  may  be  thus  expressed — a  man  is 
not  responsible  for  an  act  when,  by  reason  of  involuntary  insanity  or  de- 
lusion, he  is  at  the  time  incapable  of  perceiving  that  the  act  was  either 
WTong  or  unla^^^ul."  {People  vs.  Fine^  2  Barb.  566.)  An  illustration  of 
this  doctrine  is  the  case  of  a  man  who  might  fancy  himself  a  king,  and 
those  around  him  his  subjects.  If  such  a  person  were  to  kill  another 
Tinder  the  sui3j)osition  that  he  was  exercising  his  prerogative  as  a  king,  and 
that  he  was  called  upon  to  execute  the  other  as  a  criminal,  he  would  not 
be  deemed  responsible  for  his  act.  {Begina  vs.  ToirnJeij,  supra.)  No  less 
irresponsible  are  the  many  persons  who  imagine  that  they  act  under  the 
direct  command  of  Grod,  which  supersedes  all  human  laws  and  the  laws 
of  nature.  {Commonwealth  vs.  Rogers,  Jr.,  supra.)  A  recent  case  affords 
an  illustration  of  the  application  of  the  criterion  in  a  contrary  sense. 
{People  vs.  Taylor,  138  N.  Y.  399.)  The  defendant  Taylor  was  convicted 
of  the  murder  of  a  feUow-convict,  committed  in  one  of  the  prisons  of  the 
State  of  New  York.  After  an  assault  upon  a  keeper  of  the  prison,  he 
had  been  transferred  to  the  asylum  for  insane  convicts  upon  the  report 
of  the  ph}'siciaii  that  he  was  suffering  from  insane  melancholia  with 
suicidal  and  homicidal  tendencies.  Upon  his  subsequent  return  to  the 
prison,  he  had  been  put  to  work  in  the  broom-shoj)  not  far  from  the  de- 
ceased, mth  whom  he  had  been  previous^  on  very  friendly  terms.  After 
a  time  he  exhiljited  without  apparent  cause  a  feeling  of  great  hostility  to 
the  deceased.  The  professed  occasion  for  this  animosity  was,  as  he 
claimed,  that  he  had  been  thwarted  in  a  scheme  which  he  had  formed  of 


CENTAL  LESrOXSIBILITY  IX  ClilMIXAL    CASES.  241 

making  his  escape  by  means  of  a  g-ate-Avay,  wliicli  was  in  process  of  con- 
struction, between  the  asyhini  and  tlie  i)rison  grounds,  and  that  the  de- 
ceased had  informed  the  prison  authorities  of  liis  design  and  thus  caused 
its  failure.  It  would  seem  that  his  plan  of  escape  was  not  a  rational  one 
if  he  really  entertained  it.  It  did  not  appear  that  he  had  ever  confided 
it  to  the  deceased,  or  that  the  latter  had  informed  any  one  in  regard  to 
it,  or  that  any  person  had  told  the  defendant  that  the  deceased  had  given, 
any  such  information.  The  defendant,  having  found  a  convenient  op- 
portunity, attacked  the  deceased  with  a  knife  which  he  had  seci*eted, 
almost  severing  his  head  from  his  body.  After  the  commission  of  the 
deed  he  informed  one  of  the  keepers  that  he  had  done  it  f(jr  the  purpose 
of  being  electrocuted.  The  Court  of  Appeals,  in  its  affirmance  of  the 
judgment  of  con\iction,  referred  to  the  element  of  delusion  (p.  40G) : 
*'  Counsel  rehes  with  great  confidence  upon  the  proof  of  an  insane  delu- 
sion as  to  the  part  which  the  deceased  had  taken  in  preventing  the  exe- 
■cution  of  the  defendant's  plan  of  escape ;  but  this  delusion,  if  established, 
would  not  of  itself  be  a  sufficient  answer  to  the  present  indictment.  It 
may  be  that  if  the  question  of  its  existence  were  separately  submitted  to 
a  jury,  they  might  find,  as  we  might  be  compelled  to  find  if  submitted 
to  us,  that  the  weight  of  evidence  seemed  to  indicate  its  existence.  That 
fact,  if  conclusively  proven,  woiild  fall  far  short  of  a  defense.  An  insane 
delusion  with  reference  to  the  conduct  and  attitude  of  another  cannot 
■excnse  the  criminal  act  of  taking  his  life,  niiless  it  is  of  such  a  character 
that  if  it  had  been  true  it  would  have  rendered  the  homicide  excusable 
or  justifiable.  If  the  defendant  had  actually  planned  a  mode  of  escape 
from  prison,  and  had  confided  this  scheme  to  the  deceased,  and  the  latter 
had  betrayed  his  confidence  and  informed  the  authorities  of  his  pm-pose, 
and  by  means  of  such  information  it  had  been  frustrated,  it  would  have 
afforded  the  defendant  no  justification  for  liis  act,  but  would  have  aug- 
mented its  enormity,  because  inspii-ed  by  the  unholy  motive  of  revenge. 
How  then  can  the  false  belief,  standing  by  itself,  that  those  things  had 
happened,  affect  the  criminal  natm^e  of  the  defendant's  T^Tong  ? "  These 
-canons  determining  the  relations  of  delusion  to  criminal  responsibility 
have  found  an  acceptance  even  ampler  than  the  principal  one  enunciated 
by  the  judges,  for  they  are  recognized  as  authoritative  in  States  where 
the  criterion  of  responsiliility  is  not  limited  to  the  consciousness,  to  the 
power  to  discern  between  right  and  wi-ong,  good  and  evil.  (Pennsyl- 
vania:  CommoniveaWixii.  ^Vinnemove,B^^])V'A]  Sai/)'es  vs.  CommoniceaWi,  S^ 
Pa.  St.  291 ;  Tmjlor  vs.  The  Common  wealth,  109  Pa.  St.  262  ;  Iowa  :  State 
vs.  StklxJeij,  41  iowa,  232 ;  State  vs.  2Ieicherter,  4G  Iowa,  88.) 

It  is  to  be  noted  that  the  answers  of  the  judges  assume  that  the  limits 
of  the  disease  are  found  within  the  delusion  itself,  and  that  the  accused 
'■  is  not  in  other  respects  insane."  There  can  be  no  doubt  as  to  the  exist- 
ence of  eases  that  the  answers  of  the  judges  would  fully  cover.  If,  on 
the  other  hand,  a  delusion  considered  as  a  symptoni  l)e  e"\*idence  of 
mental  disease  extending  beyond  the  limits  of  the  delusion,  of  the  most 
extensive  mental  derangement,  a  case  is  presented  not  contemplated  by 
the  judges  in  their  answers.  The  question,  however,  as  to  the  limits  of 
the  delusion,  as  to  the  insanity  of  the  accused  in  other  respects,  like  that 
of  the  connection  between  the  delusion  and  the  act,  is  a  question  of  fact, 
not  one  of  law. 


242  ^  SYSTEM  OF  LEGAL  MEDICINE. 


THE   EMOTIONS   AND   THE   WILL. 

The  law  of  Eng-laud,  and  of  those  American  States  that  accept  the  an- 
swers in  McNag'hten's  Case,  recognizes  cerebro-mental  disease  only  in  its 
effect  npon  the  intellect  or  the  consciousness  ;  for,  in  the  consideration  of 
responsibility,  its  disturbing  influence  upon  the  emotions  and  the  will  is 
utterly  ignored.  "Everyman,"  says  Baron  Rolfe,  "is  held  responsible 
for  his  acts  by  the  law  of  this  country  [England]  if  he  can  discern  rig:ht 
from  -^vrong.  ...  It  is  true  that  learned  speculators  in  their  writings  have 
laid  it  down  that  men  with  a  consciousness  that  they  were  doing  wrong 
were  irresistibly  impelled  to  do  some  unlawful  act.  But  who  enabled 
them  to  dive  into  the  human  heart  and  see  the  real  motive  that  prompted 
the  commission  of  such  deeds?"  {Regina  vs.  Stolces,  3  C.  &  K.  185.)  If 
the  intellect  or  consciousness,  although  diseased,  be  to  that  extent  un- 
impaired that  it  is  able  to  perceive  that  the  act  is  unlawful  or  morally 
wrong,  the  insane  man  is  in  the  eyes  of  the  law  a  sane  one,  so  far  as  the 
question  of  insanity  may  affect  the  question  of  his  responsibility.  ( Willis 
vs.  People,  32  N.  Y.  715.)  In  such  a  case  the  law,  conclusively  presuming 
the  freedom  of  the  will — the  existence  of  a  power  of  choice — considering- 
the  impulses  of  insanity  as  impulses  not  uncontrollable,  but  in  fact  un- 
controlled, exacts  from  the  insane  man  a  resistance  to  them  similar  to  the 
resistance  to  human  passion  it  requu*es  from  the  sane  one.  {People  vs. 
Taylor,  supra.)  To  this  conclusion  in  a  certain  measure  has  the  law  been 
led  by  considerations  of  policy  or  convenience ;  for  in  its  estimate  any 
further  inquiry  would  be  vague  and  uncertain,  and  a  justification  and  a 
cover  for  the  commission  of  crime.  {Flanagan  vs.  People,  52  N.  Y.  467.) 
This  view  is  reflected  in  the  report  of  the  Royal  Commission  on  the 
Criminal  Code  Bill  (1878-79)  (vol.  Ixxiv.,  p.  17) :  "  The  principal  sub- 
stantial difference  between  Section  22  of  the  draft  code  and  the  corre- 
sponding section  of  the  bill  is,  that  the  latter  recognizes  as  an  excuse  the 
existence  of  an  impulse  to  commit  a  crime  so  violent  that  the  offender 
would  not  be  prevented  from  doing  the  act  by  knowing  that  the  greatest 
punishment  permitted  by  the  law  for  the  offense  would  be  instantly  in- 
flicted— the  theory  being  that  it  is  useless  to  threaten  a  person  over 
whom  by  the  supposition  threats  can  exercise  no  influence.  This  provis- 
ion of  the  bill  assumes  that  the  accused  .  .  .  was,  at  the  time  he  did  the 
act,  capable  of  appreciating  its  nature  and  quality,  and  knew  that  what 
he  was  doing  was  wrong.  The  test  proposed  for  distinguishing  between 
such  a  state  of  mind  and  a  criminal  motive,  the  offspring  of  revenge, 
hatred,  of  ungoverned  passion,  appears  on  the  whole  not  to  be  practicable 
or  safe,  and  we  are  unable  to  suggest  one  which  would  satisf.y  these  req- 
uisites and  obviate  the  risk  of  a  jury  being  misled  by  considerations  of 
so  metaphysical  a  character."  Inasmuch  as  every  crime  is  committed 
under  an  impulse  more  or  less  irresistible,  and  the  object  of  the  law  is  to 
control  su(!h  impulses,  it  is  considered  to  be  a  doctrine  the  most  danger- 
ous to  admit  as  a  defense  the  fact  of  an  impulse  being  uncontroUable, 
even  though  tlie  impulse  be  the  offspring  of  disease.  {Begina  vs.  Allnuf, 
Baron  Rolfe,  London  Times,  Deceniber  16, 1847;  Begina  vs.  Brought  Erie, 
C.  J.,  London  Times,  August  10,  1854 ;  Begina  vs.  Barton,  3  Cox,  Cr.  Ca. 
275.)  "If  an  influence  be  so  powei-ful  as  to  be  termed  irresistible," 
says  Baron  Bramwell,   "so  much   the  more  reason  is  there  why  we 


MENTAL    IlESrOXSIBILlTY  IX  CRIMINAL    CASES.  243 

slioukl  not  withdraw  auy  of  tlie  safeguards  tending  to  counteract  it. 
There  are  three  powerful  restraints  existing,  all  tending  to  the  assist- 
ance of  the  person  who  is  suffering  under  sucli  an  influence — tlie  re- 
straint of  religion,  the  restraint  of  conscience,  and  the  restraint  of  law. 
But  if  the  intluenee  itself  be  held  a  legal  excuse,  rendering  the  crime  dis- 
punishable, you  at  once  withdraw  a  most  powerful  resti-aint — tliat  for- 
bidding and  i)unisliiug  its  ])erpetration.  We  must  tlierefore  return  to 
the  simple  (piestion  you  liave  to  determine — Did  the  prisoner  know  the 
nature  of  the  act  he  was  doing,  and  did  he  know  that  he  was  doing  what 
was  wrong?''  [Regina  vs.  Haynes,  1  F.  «&  F.  GGG.)  This  same  judge  em- 
phasized similar  ^aews  before  the  select  committee  on  the  Homicide 
Law  Amendment  Act:  "AMiat  is  the  meaning  of  a  man  being  prevented 
from  controlling  his  conduct  ?  When  he  is  prevented  it  is  l^eeause  the 
preventing  motives  are  strong  enough.  ^\1ien  he  is  not  prevented  it  is 
because  they  are  not  strong  enough.  The  effect  of  this  [the  proposed 
act]  would  be  to  lessen  the  preventing  motives.  A  wishes  to  commit  a 
rape.  Disease  of  mind  weakens  his  power  of  acting  on  motives  of  chas- 
tity, religion,  morality,  goodness,  etc.,  Init  fear  of  the  law  added  to  these 
motives  makes  him  able  to  resist.  The  proposal  is  to  take  away  one  of 
liis  good  motives.  ...  I  tried  a  man  named  Dove  many  years  ago 
for  murdering  his  ^vife.  He  called  a  number  of  T\'itnesses  for  the  pur- 
pose of  proving  that  lie  could  not  control  his  actions.  There  was  one  of 
them  who,  to  prove  the  state  of  this  num's  mind,  proved  that  he  shot  a 
cat  in  the  presence  of  his  wife,  or  something  of  that  sort,  and  this  man 
gravely  said  he  believed  it  was  an  uncoutrollalile  impulse.  I  put  this 
question  to  him  (I  did  not  let  him  see  the  difficulty  it  would  lead  him  in ; 
I  got  his  mind  away  from  the  particular  answer  he  had  given) :  •  Xow, 
suppose  a  pohceman  had  been  present  when  he  shot  that  cat,  do  you  think 
he  would  have  been  restrained?'  And  he  said.  'Yes!'  'Weil,  then.'  I 
said.  '  according  to  yoiu*  \-iew  an  uncontrollalile  impulse  is  an  impulse 
acting  upon  a  man  when  a  policeman  is  not  present.'  It  is  obvious  that 
what  is  called  an  uncontrollable  impulse  is  one  as  to  which  the  deterring 
or  controlling  motives  are  not  strong  enough.  And  this  is  a  proposition 
in  all  cases  to  take  away  from  a  man.  in  a  state  of  mind  in  which  he  is 
more  likely  to  do  mischief  than  an^-thing  else,  a  deterring  motive."  (Re- 
port of  Select  Committee,  Minutes  of  Evidence,  1874,  vol.  is.,  p.  26.) 
^'  The  prisoner  was  j)i"oved  to  have  been  perfectly  well  aware."  says  Baron 
Alderson,  ••  what  he  had  done  immediately  afterward,  and  in  the  inter- 
view which  he  had  since  A^ith  one  of  the  medical  gentlemen  he  admitted 
that  he  knew  perfectly  well  what  he  had  done,  and  ascribed  his  conduct 
to  some  momentary  uncontrollable  impulse.  The  law  ilid  not  acknowl- 
edge such  an  impulse  if  the  person  was  aware  that  it  was  a  Avi-ong  act  he 
was  about  to  commit,  and  he  was  ansAverable  for  the  consequences.  A 
man  might  say  that  he  picked  a  pocket  from  some  uncontrollable  im- 
pulse, and  in  that  case  the  law  would  have  an  uncontrollable  impulse  to 
punish  him."     {Regina  vs.  Fate,  London  Times,  July  12.  ISoO.) 

This  contemplation  of  insanity,  as  limited  in  its  effects  to  the  intellect 
and  consciousness,  is  as  marked  in  the  subordinate  criteria  as  in  the 
principal  canon  itself.  In  the  distinction  dra'mi  between  an  act  the  con- 
sequence of  a  delusion,  and  an  act  founded  upon  a  real  event,  the  law, 
weighing  the  act  in  the  scales  of  responsibility,  takes  no  note  of  the 
insane  emotion  that  may  have  distorted  or  exaggerated  the  event  or  fact 


24-4  A   SYSTEM  OF  LEGAL  MEDICINE. 

giving-  rise  to  the  passion  or  emotion.  To  it  delusions  are  essentially  of 
an  objective  nature,  mere  errors  as  to  existing  facts  {Regina  vs.  Burton^. 
3  F.  &  F.  772),  and  in  the  consideration  of  them  the  law  utterly  excludes 
the  emotions  as  factors  of  responsibility.  For  assuming  a  delusion  to 
be  that  the  accused  had  suffered  a  wi-ong  at  the  hands  of  another,  by 
arbitraril}^  ascribing  the  inspiration  of  the  act  to  the  "unholy  passion  of 
revenge"  [People  vs.  Taylor,  supra),  and  by  exacting  from  the  insane  mau 
a  sane  resistance  to  such  supposed  passion,  the  law  totally  excludes  from 
its  consideration  au}^  disorder  of  the  emotional  nature  produced  b}^  the 
insanity  of  which  the  delusion  may  only  be  a  symptom.  This  legal  view 
of  insanity,  which  interprets  tlie  answers  of  the  judges  in  their  natural 
and  restricted  sense,  prevails,  as  has  been  said^  in  England  and  in  the- 
following  of  the  United  States  of  America : 

CALIFORNIA. 

People  vs.  Hoin,  62  Cal.  120. 

GEORGIA. 

Anderson  vs.  State,  42  Geo.  10. 

MINNESOTA. 

state  vs.  Scott,  41  Minn.  365. 

NEW   JERSEY. 

State  vs.  Grams,  5  N.  J.  L.  J.  54. 

NEW  YORK. 

Waller  vs.  People,  88  N.  Y.  82 ;  People  vs.  Carpenter,  102  N.  Y.  238, 

DISTRICT   OF   COLTOIBIA. 

JJ.  S.  vs.  Guiteau,  1  Mackey,  498. 

Having  its  foundation  on  metaphysical  a  priori  reasoning  this  theory 
of  insanity  has  met  with  the  most  relentless  opposition  from  medical 
science,  which  claims  for  its  conclusions  a  weight  due  to  extended  obser- 
vation and  experiment.  Inasmuch  as  the  consciousness  of  right  and 
wrong  can  be  proved  to  exist  in  any  condition  of  mind  above  that  of  "  an 
infant,  a  brute,  or  a  wild  beast " ;  in  any  degree  of  insanity  which  does 
not  extend  to  the  total  deprivation  of  memory  and  understanding ;  and 
as  this  consciousness,  as  a  criterion,  could  consequently  only  apply  to  the 
furious  maniac,  the  confirmed  idiot,  or  the  actively  delirious,  and  would 
consequently  include  the  greater  number  of  the  ordinary  inmates  of  in- 
sane asylums,  the  majority  of  general  intellectual  maniacs,  and  a  still 
larger  proportion  of  partial  intellectual  maniacs,  medical  science  rejects- 
it  as  a  true  criterion  of  moral  responsibility.  In  addition,  the  contem- 
plation of  insanity  as  a  disease  exclusively  a.ffecting  the  intellect  or  the 
consciousness,  thns  ignoring  the  disordered  emotions  and  the  will  as 
factors  of  responsibility,  is  said  to  be  opposed  to  the  essential  pathology 
of  the  disease,  which  is  primarily  a  disorder  of  man's  emotional  nature. 


MENTAL  RESrONSIBILITY  IN  CRIMINAL   CASES.  24. "3 

^^  ResponsihUitji  (Icpauh  upon,  poircr,  not  upon.  Jaioiclcdfje,  .sfill  less  upon 
feeling.  A  man  is  responsible  to  do  iluif  whieh  he  ean  do,  not  tluit  ivhieh  lie 
feels  or  knoics  it  riylit  to  do''  (Biicknill  on  Criminal  Lnndci/,  p.  59);  a 
ci'iiniii;il  beiu^-  properly  puiiislialilc,  not  l)ee;iuse  lie  knows  •^•ood  from 
evil,  but  beeiuise  lie  voluntarily  did  the  evil,  liaving-  tlio  power  to  choose 
the  good.  (Ogston's  Lectures  on  Medical  Jurisprudence,  Lecture  XXL  ; 
Biicknill  and  Tuke's  Psjiehologieal  Medicine,  j).  2G9  ;  Review  of  Dr.  Janiiesou 
on  "  Criminal  Kesponsibility  of  Insane,"  4  Fsi/ehological  Journal,  p.  187.) 
Many  of  tlie  jurists  of  England  have  borne  testimony  as  to  the  diffi- 
culty of  making  the  legal  criterion  a  rule  of  universal  application — a 
criterion  embodying  such  a  definition  of  legal  madness  '^  that  nobody  is 
hardly  ever  really  mad  enough,  to  be  within  it,"  which  is  the  frank  ad- 
mission of  Baron  Brainwell,  who  certainly  cannot  be  charged  with  sen- 
timental tenderness  toward  the  insane.  (Reports  of  Committees,  Minutes 
of  Evidence,  1874,  vol.  ix.,  p.  27.)  Before  the  select  committee  on  the 
Homicide  Law  Amendment  Act,  which,  drafted  by  Sir  J.  F.  J.  Stephen, 
would  have  introduced  into  the  criterion  of  responsibility  the  additional 
element,  the  prevention  by  any  disease  affecting  the  mind  of  the  power 
of  controlling  the  conduct  (Homicide  Law  Amendment  Act,  part  ii.,  sec. 
24:d),  Mr.  Justice  Blackburn  gave  the  following  testimony:  "We  cannot 
fail  to  see  that  there  are  cases  where  the  person  is  clearly  not  i-esponsible 
and  yet  knew  right  from  wrong.  I  can  give  you  au  instance  which 
shows  what  I  held  deliberately ;  it  was  in  the  case  of  that  w^oman  whom 
I  was  speaking  of,  who  was  tried  for  wounding  a  girl  with  intent  to 
murder.  The  facts  were  these :  the  woman  had  more  than  once  been 
insane,  insanity  being  principally  brought  on  by  suckling  her  child  too 
long ;  that  was  the  cause  that  had  produced  it  before.  She  was  living 
with  her  husband,  and  had  charge  of  this  girl,  a  girl  of  about  fifteen,  an 
impotent  girl  who  lay  in  bed  all  day.  She  was  very  kind  to  liei',  and 
treated  her  very  well.  They  were  miserably  poor,  and  very  much  o^wiiig 
to  that  she  continued  to  nurse  her  boy  till  he  was  nearly  two  years  old, 
and  suddenly,  when  in  this  state,  she  one  morning,  about  eleven  o'clock, 
went  to  the  child  lying  there  in  bed,  aged  fifteen,  and  deliberately  cut 
her  throat.  Then  she  went  toward  her  own  child,  a  girl  of  fi^'e  or  six 
years  of  age,  of  whom  she  was  exceedingly  fond,  and  the  girl  hearing  a 
noise  looked  up  and  said,  '  What  are  you  doing V  'I  have  killed  Olivia, 
and  I  am  going  to  kill  you,'  was  the  answer.  The  child,  fortunately,  in- 
stead of  screaming,  threw  her  arms  around  her  mother's  neck  and  said, 
'  No,  I  know  you  Avould  not  hurt  your  darling  little  Mopsy.'  The  woman 
dropped  the  child,  went  downstairs  and  went  into  a  neighbor's  house, 
told  her  what  she  had  done,  that  she  had  kiUed  Olivia  and  was  going  to 
kill  Mary,  but  '  when  the  darling  threw  her  arms  around  my  neck  I  had 
not  the  heart  to  do  it.'  She  cleaily  knew  right  from  ^\Tong,  and  knew 
the  character  of  her  act,  for  some  little  time  after  that  she  talked  ration- 
ally enough ;  but  before  night  she  was  sent  to  a  lunatic  asylum,  raving- 
mad,  and  having  recovered  she  was  brought  to  be  tried  before  me  at  a 
subse(|uent  assize.  On  the  definition  in  McNaghten's  Case,  she  did  '  know 
right  from  wrong';  she  did  not  [sic]  know  the  quality  of  her  act,  and 
was  quite  awai-e  of  what  she  had  done,  but  I  felt  it  impossible  to  say  that 
she  should  be  punished.  If  I  had  read  the  definition  in  McXagh ten's 
Case  and  said,  'Do  you  bring  her  within  that?'  the  jury  woidd  have 
taken  the  bit  in  their  own  teeth  and  said,  '  Xot  guilty  on  the  ground  of 


246  ^   SYSTEM  OF  LEGAL  MEDICLNE. 

insanity.'  I  did  not  do  that.  I  told  them  that  there  were  exceptional 
cases,  and  on  that  the  jnry  found  her  not  guilty  on  the  ground  of  in- 
sanity, and  I  think  rightly.  On  this  definition  I  think  you  would  be 
oblig-ed  to  say  that  woman  was  guilty."  (Reports  of  Committees,  Minutes 
of  Evidence,  1874,  vol.  ix.,  p.  11.)  Of  similar  tenor  were  the  views  ex- 
pressed by  the  Lord  Chief -Justice  Cockburn  in  a  memorandum  submitted 
to  this  same  committee  :  "  As  the  law,  as  expounded  by  the  judges  in  the 
House  of  Lords,  now  stands,  it  is  only  when  mental  disease  produces  in- 
capacity to  distinguish  between  right  and  wrong  that  immunity  from  the 
penal  consequences  of  crime  is  admitted.  The  present  bill  introduces  a 
new  element,  the  absence  of  the  power  of  self-control.  I  concur  most 
cordially  in  the  proposed  alteration  of  the  law,  having  always  been 
strongly  of  opinion  that,  as  the  pathology  of  insanity  abundantly  estab- 
lishes^ there  are  forms  of  mental  disease  in  which,  though  the  patient  is 
quite  aware  that  he  is  about  to  do  wrong,  the  will  becomes  overpowered 
by  the  force  of  irresistible  impulse.  The  power  of  self-control,  when  de- 
stroyed or  suspended  by  mental  disease,  becomes,  I  think,  an  essential 
element  of  responsibility."  (Reports  of  Committees,  Special  Report  Select 
Committee,  No.  1,  1874,  vol.  ix.,  App.  No.  1.) 

In  a  recent  charge  to  the  grand  jury  at  the  Shropshire  winter  assizes 
Mr.  Justice  Hawkins  referred  to  the  case  of  one  Anthony  Ware,  charged 
with  the  murder  of  one  Smith  at  the  Salop  and  Montgomery  County 
Asylum,  Bicton,  near  Shrewsbury.  After  the  homicidal  act  was  com- 
mitted, the  patient  was  removed  to  Broadmoor.  Under  these  circum- 
stances, the  finding  of  a  true  bill  did  not  come  under  the  consideration 
of  a  jury.  The  judge,  however,  regarded  the  case  as  so  very  interesting 
that  he  went  out  of  his  way  to  comment  upon  it  to  the  grand  jury.  It 
appears  that  Ware  had  been  for  a  considerable  time  a  dangerous  lunatic. 
Dr.  Strange,  the  medical  superintendent  of  the  Bicton  asylum,  stated 
that  while  he  had  been  a  patient  at  the  County  Asylum  he  had  com- 
mitted several  murderous  assaults  upon  patients,  and  in  one  instance 
upon  an  attendant.  On  the  fatal  day  this  homicidal  patient  had  been 
out  for  an  airing  with  another  dangerous  lunatic  named  Smith.  Indeed 
there  seemed  to  be  some  fifteen  or  sixteen  patients  of  the  class  together. 
On  returning  to  the  asylum.  Ware  provided  himself  with  an  iron  bar 
from  a  bedstead,  and  was  seen  by  the  attendant  in  charge  to  strike  the 
deceased  (Smith)  upon  the  head  with  it.  From  the  wounds  thus  received 
the  latter  quickly  died.  As  Ware  threatened  to  murder  every  one  who 
approached  him,  prompt  assistance  could  not  be  rendered  to  save  Smith's 
life.  Having  called  attention  to  the  answers  of  the  judges,  his  lordship 
requested  the  jury  to  apply  them  to  the  case  in  question,  in  which  no 
one,  lawyer  or  layman,  would  venture  to  say  that  the  wretched  man  is 
responsible  for  the  act  he  committed ;  yet,  although  he  was  a  confirmed 
lunatic,  he  was  perfectly  aware,  according  to  the  depositions,  of  the 
nature  of  the  act.  It  was  quite  clear,  from  what  he  himself  had  said, 
that  he  had  kiUed  some  one,  and  that  he  was  also  aware  that  what  he 
had  done  was  wrong ;  for  he  extracted  a  promise  that  he  should  not  be 
punished  if  he  gave  up  the  iron  bar  that  he  had  in  his  possession.  "  This 
l»eing  so,  it  would  be  impossible  to  say  that  Ware  did  not  know  that  he 
liad  killed  a  man,  because  he  said  himself  that  he  had;  and  it  would  be 
impossible  for  anybody  to  urge  that  he  did  not  know  it  was  wrong,  for 
he  wanted  a  promise  that  he  should  not  be  })uuished ;  but  unless  one  put 


MENTAL  BESrONSIBILITY  IX  CUIMIXAL   CASES.  247 

a  totally  different  eonstruction  on  the  law,  that  wonld  have  to  be  proved ; 
altlion<;'h  no  man  in  liis  senses  would  suppose  that  any  jury  would  find 
Ware  resp()nsil)le  for  what  he  had  done."  Mr.  Justice  Hawkins  stated 
in  additi(»n  that  he  had  not  only  spoken  his  own  views  upon  the  matter, 
for  more  than  one  of  the  judii'es  had  expressed  the  desire  that  the  law 
upon  the  subjeet  should  l)e  revised  and  a  little  more  definite  understand- 
ing arrived  at.  (^Ir.  Justice  Hawkins  on  ''  The  Plea  of  Insanity'  in  Crim- 
inal Cases,"  Journal  of  Mental  IScience,  vol.  xxxi.,  p.  64t.)  Expressions  of 
opinion  as  to  the  incompleteness  or  inadequacy  of  the  criterion  are  not 
confined  to  the  judges  of  England.  The  trial  of  xVndrew  Kleim  was  had 
before  Mr.  Justice  Edmonds  of  the  Supreme  Court  of  the  State  of  New 
York.  The  prisoner  had  been  indicted  for  the  willful  murder  of  one 
Catharine  Hanlon.  The  deceased,  with  her  husband  and  children,  re- 
sided in  a  wooden  shanty  or  dwelling,  the  (jnly  door  of  which  was  in  the 
front,  about  five  yards  from  the  prisoner's  residence.  One  morning,  be- 
tween six  and  seven  o'clock,  the  prisoner  came  out  of  his  house  and  piled 
wood-shavings  and  straw  at  the  door  of  the  deceased's  residence,  to  which 
he  then  set  fire.  The  deceased  attempted  to  escape  through  the  door,  but 
was  forcibly  thrust  back  by  the  prisoner,  who  stabbed  her  in  the  thigh 
with  a  sharp  instrument  attached  to  a  stick.  She  went  to  a  window 
with  her  son,  a  boy  of  about  thirteen  years  of  age,  Avhen  the  prisoner 
threatened  to  cut  her  throat ;  she  then  swooned  away  and  became  sense- 
less. The  defense  was  insanity,  and  upon  a  prehmiuary  inquiry  the  jury 
found  that  the  prisoner  was  not  then  insane.  Upon  the  subsequent  trial 
upon  the  main  issue,  the  jmy  retm-ned  a  verdict  of  "■  not  gaiilty  "  upon  the 
ground  of  insanity.  "  The  first  case  of  insanity  that  came  before  me  as 
judge,"  says  Mr.  Justice  Edmonds,  "  was  this  case  of  Kleim.  In  the  pre- 
liminary inquiry  into  present  insanity,  I  followed  this  rule  (McXagliten's 
Case),  and  the  ^'crdict  of  the  jury  at  once  satisfied  me  that  it  had  misled 
them,  for  he  was  not  totally  but  only  '  partially  insane.'  and  he  did  know 
that  it  was  wrong  to  shut  that  woman  and  her  children  in  theii*  hut  and 
burn  them  to  death;  yet  there  was  no  doubt  of  his  insanity,  and  in  less 
than  a  year  he  became  a  mere  driveling  idiot,  and  so  died.  He  knew  the 
act  was  wrong,  yet  he  was  insane.  The  act  of  piling  up  shaAangs,  fasten- 
ing the  woman  in  her  hut,  and  forcing  her  back  into  the  flames,  was 
not  an  '  involuntary  act  of  the  body  without  the  concm-rence  of  a  mind 
-directing  it,'  *  yet  he  was  insane.  He  knew  the  '  act  was  contrary  to  the 
plain  dictates  of  justice  and  right,  injurious  to  others,  and  a  A^olation  of 
the  dictates  of  duty,'  t  yet  he  was  insane.  He  knew  •  he  was  acting  con- 
trary to  law,'  yet  he  was  insane.  He  kucAV  the  act  was  '  one  he  ouglit 
not  to  do,'  vet  he  was  insane."  (Note  to  People  vs.  Andrew  Kleim,  1  Edm. 
■Sel.  Ca.  28.') 

A  recent  case  tried  at  the  Taunton  assizes,  England,  affords  a  strildng 
proof  of  the  possible  coexistence  of  extraordinary  insanity  and  all  the 
conditions  that  might  In-ing  an  accused  within  the  lettei-  of  McXagliten's 
■Case.  {'-Rcgina  vs^  IlifcJiens,"  by  Cliarles  Mercier,  Lancet.  March  3^1888.) 
The  prisoner,  a  lad  of  twenty-one,  had  suffered  for  many  years  from  epi- 
lepsy, which  had  been  getting  more  severe.  His  mother  had  been  on 
two  occasions  insane,  the  second  occasion  being  shortly  before  the  bii-th 
of  the  prisoner.     One  morning,  before  he  was  fully  dressed,  the  prisoner 

*  Shaw,  C.  J.,  Commnnuralth  vs.  Bogcrs,  Jr.,  supra.  t  Ibid. 


248  ^   SYSTEM  OF  LEGAL  MEDICINE. 

■went  into  the  bedroom  of  his  eldest  sister,  who  was  in  bed,  and  blew  her 
brains  ont  with  one  discharge  from  a  double-barreled  gun.  He  then  fired 
two  shots  from  the  same  gan  at  his  own  head,  but  only  slightly  wounded 
himself.  He  then  rushed  out  of  the  room  and  plunged  head-foremost 
down  a  flight  of  sfcau-s.  He  did  not  slip  or  fall  down,  but  threw  himself 
down  with  his  hands  up,  as  if  diving  into  water.  After  this  he  got  up  and 
threw  himself  in  the  same  way  down  a  second  flight  of  staii-s.  He  again 
got  up  and  threw  himself  in  the  same  way  into  a  flreplace.  Being  taken 
and  put  to  bed,  he  told  his  father  to  look  into  the  pockets  of  a  coat  that 
was  hanging  in  his  room.  There  the  father  found  the  following  letter : 
"■  I  leave  everything  that  belongs  to  me  to  my  dear  mother.  I  have  been 
treated  so  badly  by  that  beast,  my  sister  Constance,  that  I  must  put  an 
end  to  her  life  by  shooting ;  and  knowing  that  I  should  have  to  die  for 
it,  I  also  shoot  myself.  Good-by  to  all !  Hoping  you  will  have  a  happy 
time  of  it,  good-by,  dear  father  and  mother  !  "  The  prisoner  subsequently 
said  several  times  to  different  people  that  his  sister  had  been  very  unkind 
to  him,  and  had  been  a  bad  one  to  him.  It  did  not  appear  at  the  trial^ 
however,  that  he  had  previously  shown  animosity  toward  her  beyond 
that  usually  displayed  in  mere  children's  squabbles,  and  the  only  com- 
plaints he  had  ever  made  against  her  were  that  she  had  not  given  him 
a  news^Daper  when  he  asked  for  it,  and  that  she  had  passed  him  in  the 
street  without  speaking.  The  prisoner,  at  the  instance  of  the  Crown,  had 
been  examined  previously  to  the  trial  by  medical  experts,  who  at  the 
trial  itself  gave  testimonj'-  for  the  defense  under  circumstances  of  great 
difficulty,  owing  to  the  rulings  of  the  trial  judge.  It  appeared  in  evi- 
dence that  the  epilepsy  to  which  the  accused  was  subject  included  both 
forms  of  epileptic  paroxysm,  namely,  U  liaut  and  le  petit  mcd,  and,  in 
addition,  physical  symptoms  proved  to  the  medical  mind  at  least  the 
fact  of  the  prisoner's  extreme  insanity.  The  summing  up  of  the  judge 
(Mr.  Justice  Field)  was  very  strong  against  the  prisoner.  He  declared 
that  all  the  conversations  narrated  and  all  the  acts  of  the  prisoner  were 
perfectly  rational.  He  took  the  letter  written  by  the  prisoner,  and  read- 
ing it  sentence  by  sentence,  asked  if  each  sentence  was  not  a  rational  one. 
He  told  the  jury  that  the  question  for  them  was,  "  Did  the  prisoner  know 
the  nature  and  quality  of  the  act  he  had  committed ;  that  it  was  con- 
demned by  the  laws  of  G-od  and  man,  and  if  he  committed  it  that  he 
would  have  to  suffer  death  for  itf "  The  judge  further  charged  the  jury 
that,  even  if  they  were  satisfied  that  the  prisoner  was  insane  at  the  time 
of  the  crime,  they  could  not  retm-n  a  verdict  of  "  guilty,"  but  "  insane," 
unless  they  found  that  he  was  suffering  from  such  a  delusion  that,  if  the 
facts  really  had  been  as  he  deludedly  believed  them  to  be,  he  could  have 
legally  committed  the  act  for  which  he  was  tried.  After  a  short  absence 
the  jury  retarned  a  verdict,  according  to  the  recent  statute,  of  '^  guilty, 
but  insane  at  the  time  the  act  was  committed."  The  repeated  occurrence 
of  these  "  exceptional  cases"  referred  to  by  Mr.  Justice  Blackburn — cases 
where  palpable  irresponsibility  coexists  with  an  evident  knowledge  of  the 
difference  between  right  and  wrong — has  compelled  the  judges,  to  avoid 
the  commission  of  the  most  manifest  injustice,  to  depart  from  the  crite- 
rion. These  facts  furnish  a  very  strong  practical  argiunent  against  the 
criterion  as  being  a  rule  complete  in  itself. 

At  the  trial  of  Joseph  GiU,  at  the  Leeds  assizes,  in  April,  1883,  Mr. 
Justice  Kay  charged  the  jury  that  ''the  most  important  question  was. 


MEJSTAL   RESrOXSinilATY  IX  CRIMINAL   CASES.  049 

"Were  they  dealing  with  a  sane  man  ?  Judges  luid  said  over  and  over 
again  that  a  man  c.oiihl  not  be  considered  insane  merely  because  he  did 
a  criminal  act,  and  the  importance  of  that  view  could  not  l)e  overesti- 
mated. Nevertheless,  he  did  not  agree  with  the  learned  ccnmsel  who  put 
it  that  'it  was  necessary  to  prove  that  a  man  did  not  know  the  dili'er- 
ence  between  right  and  wrong  in  order  to  show  that  he  was  insane.'  If 
a  man's  mind  was  in  such  a  diseased  condition  that  he  was  subject  to 
uncontrollable  impulse,  they  would  be  justified  in  finding  him  irresponsi- 
ble for  his  actions.  What  the  jury  had  to  ask  themselves  was,  Was  the 
prisoner's  mind  subject  to  an  uncontrollable  im2:>ulse  over  which  his  will 
had  no  power  f  If  so,  they  nnist  acquit  him  on  the  ground  of  insanity." 
(Review  of  "History  of  the  Criminal  Law  of  England,''  by  Stephen,  f/o«;-- 
nal  of  Mental  Science,  vol.  xxix.,  p.  258.)  So  also  in  a  recent  case,  Mr.  Jus- 
tice Lawrence  put  thus  the  question  to  the  jury :  "  Was  the  prisoner  un- 
able to  control  his  actions  in  consequence  of  disordered  mind?"  (The 
Duncan  Case,  Journal  of  Mental  Science,  vol.  xxxvii.,  p.  562.)  As  the  lead- 
ing canon,  so  have  the  subordinate  criteria  in  relation  to  delusions  met 
with  adverse  and  destructive  criticism.  As  has  been  said,  these  answers 
of  the  judges  have  for  their  basis  the  assmnption  that  the  accused  is  "  not 
in  other  respects  insane  "  ;  that  the  effect  of  the  delusion  is  to  ^n'oduce  an 
intellectual  error  as  to  an  existing  fact,  the  limits  of  which  are  found 
within  the  delusion  itself.  It  is  held  by  the  most  distinguished  authority 
that  the  fact  of  an  illegal  act  being  conunitted  from  the  point  of  view  of 
a  fixed  delusion  is  in  itself  a  proof  that  the  reason  of  the  accused  has 
lost  control  of  the  fixed  idea,  and  that  the  delusion  itself  has  ceased  to 
be  a  limited  one.  (Casper's  Handhool)  of  Forensic  Medicine,  part  vi.,  vol.  iv., 
chap,  ii.,  sec.  80.)  Be  this  as  it  may.  the  answers,  even  upon  their  as- 
sumption of  a  partial  or  hniited  delusion,  have  not  met  ^itli  acquies- 
cence ;  and  adverse  criticism  in  support  of  its  position  as  to  their  intrinsic 
unreasonableness  urges  as  objections :  the  arbitrary  imposition  of  limits 
upon  a  disease  so  subtile  and  mysterious  as  that  of  insanity  5  the  at- 
tributing to  madness  the  delusive  imaginary  fact,  and  to  sanity  the 
emotion  or  passion  arising  out  of  that  fact;  the  judgment  of  these 
emotions  or  passions  from  a  standpoint  of  sanity,  by  the  exaction  from 
the  accused  of  a  sane  conduct  in  reference  to  them,  thus  eliminating- 
any  influence  of  the  disease  upon  the  emotions  and  the  will.  {State  vs. 
Jones,  60  N.  H.  369 ;  Parsons  vs.  State,  81  Ala.  577.)  This  elimination, 
it  is  claimed,  essentially  contradicts  the  pathology  of  delusions  as  symp- 
toms of  mental  derangement.  Medical  science  assures  us  that  '^  a  delu- 
sion .  .  .  never,  or  hardly  ever,  stands  alone,  but  is  in  aU  cases  the  result 
of  a  disease  of  the  brain,  wdiich  interferes  more  or  less  with  every  function 
of  the  mind,  which  falsifies  aU  the  emotions,  alters  in  an  unaccountable 
way  the  natural  weight  of  motives  of  conduct,  weakens  the  will,  and 
sometimes,  without  giving  the  patient  false  impressions  of  external  facts, 
so  enfeebles  every  part  of  his  mind  that  he  sees  and  feels  and  acts  -\Wth 
regard  to  real  things  as  a  sane  man  does  with  regard  to  what  he  sup- 
poses himself  to  see  in  a  dream.  .  .  .  Suppose,  for  instance,  that  by  i-ea- 
son  of  the  disease  of  the  brain  a  man's  mind  is  filled  with  delusions  which, 
if  true,  woidd  not  justify  or  excuse  his  proposed  act,  but  which  in  them- 
selves are  so  wild  and  astonishing  as  to  make  it  impossil)le  for  him  to 
reason  about  them  calmly,  or  to  reason  cahnly  upon  matters  connected 
with  them.     Suppose,  too,  that  the  succession  of  insane  thoughts  of  one 


250  A  systjEM  of  legal  medlcine, 

kind  and  another  is  so  rapid  as  to  confuse  liim ;  and  finally  suppose  that 
his  will  is  weakened  by  his  disease,  that  he  is  unequal  to  the  effort  of 
calni  sustained  thoug'ht  upon  any  subject,  and  especially  upon  subjects 
connected  with  his  delusion — can  he  be  said  to  know  or  have  a  capacity 
of  knoAving  that  the  act  which  he  proposes  to  do  is  wrong?"  (Stephen's 
Historij  of  the  Crimmal  Law  of  England ,  vol.  ii.,  chap,  xix.,  pj).  157,  164.) 
As  a  solution,  Sir  J.  F.  J.  Stephen  would  construe  the  answers  of  the 
judges  in  a  broader  and,  as  it  were,  a  "  non-natural "  sense :  the  word 
"know"  including,  in  his  opinion,  not  knowledge  only,  but  the  power  of 
controlling  the  conduct  as  well:  "Knowledge  and  power  are  the  constit- 
uent elements  of  all  voluntary  action,  and  if  either  is  seriously  impaired 
the  other  is  disabled.  It  is  as  true  that  a  man  who  cannot  control  him- 
self does  not  know  the  nature  of  liis  acts  as  that  a  man  who  does  not 
know  the  nature  of  his  acts  is  incapable  of  self-control."  His  proposition 
is,  "  that,  if  it  is  not,  it  ought  to  be  the  law  of  England  that  no  act  is  a 
crime  if  the  person  who  does  it  is  at  the  time  when  it  is  done  prevented 
either  by  defective  mental  power  or  by  any  disease  affectinr  his  mind 
from  controlling  his  own  conduct,  unless  the  absence  of  the  power  of 
self-control  has  been  produced  by  his  own  default."  (Stephen's  History 
of  the  Criminal  Laiv  of  England,  vol.  ii.,  chap,  xix.,  p.  168.)  In  the  opinion 
of  the  Lord  Chief -Justice  Cockburn,  the  doubts  and  difficulties  suggested 
by  the  answers  of  the  judges  have  been  due  to  a  construction  too  wide 
and  general,  and  to  their  not  having  been  ajDplied  strictly  with  reference 
to  the  questions  put :  "  Among  the  functions  of  the  human  mind  liable 
to  be  perverted  by  disease  is,  as  all  scientific  writers  on  insanity  are 
agi'eed,  the  human  will :  which  sometimes  becomes  the  slave  of  maniacal 
impulses,  which  it  is  unable  to  resist.  Among  the  different  forms  of 
madness  by  which  the  will  is  liable  to  be  thus  affected  is  that  which  is 
known  by  the  name  of  homicidal  mania,  or  when  it  compels  a  person  to 
self-destruction,  suicidal  mania.  That  the  will  is  liable  to  be  thus  maniac- 
ally affected,  and  so  to  be  swayed  by  impulses  which  it  is  unable  to  resist, 
is  a  point  on  which  writers  on  mental  pathology  are  agreed.  Instances 
have  been  known  in  which  lunatic  patients  have  been  periodically  thus 
affected,  and,  conscious  of  the  approach  of  the  maniacal  condition,  have 
requested  to  l)e  placed  under  restraint.  Murders  for  which  no  motive 
could  be  suggested,  sometimes  of  childi-en  by  their  own  mother,  self-mur- 
der, equally  without  adequate  motive,  by  men  of  religious  character,  can 
often  only  be  thus  accounted  for.  Ought  persons,  who,  thus  afflicted, 
commit  crimes,  to  be  punished  as  though  they  were  of  sound  mind  and 
capable  of  the  self-restraint  wdiich  the  sense  of  moral  right  and  wrong  or 
the  fear  of  the  law  imposes  upon  others  more  happily  constituted  ?  The 
point  cannot  as  yet  be  said  to  have  been  authoritatively  determined. 
The  language  of  the  judges  in  the  House  of  Lords  has,  no  doubt,  been 
repeated  as  of  general  application,  but  erroneously.  Their  answers  had 
reference  to  the  sj>eciftc  questions  put  them  by  the  House,  the  language 
of  whic'h  was  in  these  terms :  '  What  is  the  law  respecting  alleged  crimes 
committed  by  persons  afflicted  with  insane  delusions  in  respect  of  one 
or  more  particular  suljjects  or  persons?'  The  answer  is  restricted  to 
the  specific  question  so  put.  'Assuming,'  it  begins,  Hhat  your  inquiries 
are  confined  to  those  persons  who  labor  under  such  partial  delusion  only 
and  are  not  in  other  respects  insane,  we  are  of  opinion,'  etc. — the  answer 
thus  excluding  any  other  form  of  insanity  save  that  of  partial  delusion, 


MENTAL   UKsroXsiIllLirv    IX    CIUMINAL    CASES.  2~)1 

and  c(>us('(jU('Jitly  not  toucliing'  the  case  of  mania,  to  wliicli  I  am  at  pres- 
ent directing  attention.  Fnrther  questions  are  put  as  to  the  questions 
to  be  put  to  the  jury  wlien  a  person  liaving"  insane  dehisions  is  charged 
with  (u-ime,  and  insanity  is  set  up  as  a  defense,  find  the  answers,  as  l)e- 
fore,  have  refereuct^  t>idy  to  tlie  questions  put,  tljat  is  to  say,  as  to  the 
effect  of  insane  dehisions  as  a  defense.  Tlic  point  has  not  come  under 
judicial  discussion  in  a  case  which  really  raised  the  cpiestion.  The  near- 
est approach  to  it  was  in  the  case  of  lipgina  vs.  JJiirfoii,  reported  in  3  F. 
&  F.  772,  where  the  prisoner,  a  hid  of  eighteen,  had  murdered  a  boy,  con- 
fessing the  fact  afterward,  and  accounting  for  it  by  saying  '  he  had  made 
up  his  mind  to  murder  some  one,  as  he  was  tired  of  life.'  There  was 
insanity  in  the  boy's  family,  liis  mother  having  been  twice  confined  in 
a  lunatic  asylum,  but  the  defense  set  up  being  homicidal  mania  and  the 
want  of  self-control,  there  was  no  evidence  of  the  latter  in  anything  but 
the  fact  itself.  The  summing  up  of  the  learned  judge,  Mr.  Justice  Wight- 
man,  cannot,  I  think,  be  considered  as  satisfactory.  While  depreciating- 
the  doctrine  of  homicidal  nuxnia  as  a  highly  dangerous  doctrine,  he  went 
the  length  of  saying,  founding  himself  upon  the  supposed  doctrine  of  the 
judges,  which  he  mistook,  that  to  entitle  a  man  to  be  acquitted  on  the 
ground  of  insanity  there  must  be  '  delusion '  and  '  inability  to  distinguish 
right  from  wrong,'  whereas  the  question  whether  mania  accompanied  by 
insane  impulses  might  afford  a  defense  was  not  submitted  to  the  judges  or 
involved  in  their  answers.  The  question  whether  under  the  influence  of 
mental  disease  the  human  will  may  become  subject  to  impulses  which  it 
is  unable  to  resist,  and  upon  which  even  the  fear  of  death  will  not  oper- 
ate as  a  restraint,  is  not  one  for  lawyers  to  disposa  of  dogmatically^  as 
they  often  do,  but  one  which,  as  a  question  of  patliological  science,  it  is 
for  men  conversant  with  that  science  to  decide.  If  the  fact  is  estal)- 
lished,  as  I  believe  it  to  be,  it  is  for  the  enlightened  and  philosophic  law- 
giver, in  the  interest  of  justice  and  humanity  on  the  one  hand  and  of  so- 
ciety on  the  other,  to  determine  whether  an  act  done  in  such  a  condition  of 
the  mind  shall  subject  a  man  to  punishment."  (Letter  relating  to  the  Crim- 
inal Code,  Indictable  Offenses  Bill,  Papers,  vol.  liv.,  p.  232.)  With  these 
latter  views  ai'e  the  Continental  jurists  agreed.  With  them  the  "  faculty  of 
choosing  between  good  and  evil,"  or  "the  power  to  act  with  freedom,"  is  not 
necessarily  included  in  the  capacity  to  know  right  from  wrong;  Mitter- 
maier  holding  that  two  conditions  are  required  to  constitute  the  freedom  of 
the  will,  which  is  essential  to  responsibility,  namely,  a  knowledge  of  good 
and  evil  and  the  faculty  of  choosing  between  them.  (Review  of  Mittermaier 
on  "The  Excuse  of  Insanity,"  Amerkmi  Jurist,  vol.  xxii.,  pp.  312,  313; 
Casper's  Haiulhooli  of  Forensic  Medicine,  vol.  iv.,  part  vi.,  chap,  ii.,  sec.  80.) 
The  effect  of  mental  disease  upon  the  emotions  and  the  will,  and  the 
consequent  power  of  controlhng  the  conduct,  are  recognized  as  essential 
elements  of  responsibility  in 

ALABAMA. 

By  the  loss  of  the  power  of  choosing  between  right  and  wi'ong 
through  the  duress  of  mental  disease.    Parsons  vs.  State,  81  Ala.  577. 

CONNECTICUT. 

By  the  irresistible  impulse  arising  from  disease.     State  vs.  Johnson, 
40  Conn.  136. 


252  A   STSTUM  OF  LEGAL  MEDICINE. 


ILLINOIS. 


By  an  uncontrollable  impulse  to  do  the  act  cliarged,  which  deprives 
the  accused  of  the  power  to  choose  between  the  right  and  the  wrong, 
Hopps  vs.  People,  31  lU.  385. 


INDIANA. 


By  the  loss  of  the  power  of  self-control  through  mental  disease. 
Stevens  vs.  State,  31  Ind.  485 ;  Bradley  vs.  State,  31  Ind.  492 ;  Conway  vs. 
State,  118  Ind.  482. 


IOWA. 


By  an  uncontrollable  and  irresistible  impulse  arising  from  mental 
disease.     State  vs.  Felter,  25  Iowa,  67 ;  State  vs.  Meivherter,  46  Iowa,  88. 


MICHIGAN, 

By  the  loss  from  insanity  of  the  power  to  resist  temptation  to  violate 
the  law.    People  vs.  Finley,  38  Mich.  482, 

PENNSYLVANIA, 

By  the  loss  through  disease  of  the  power  of  self-control  and  the  free- 
dom of  moral  action,  ''  the  morbid  propensity  existing  to  such  an  extent 
as  to  subjugate  the  intellect,  control  the  will,  and  render  it  impossible  to 
do  otherwise  than  yield  thereto."  Taylor  vs.  Commonwealth,  109  Pa.  St. 
262 ;  Commonu'eaWi  vs.  Winnemore,  1  Brewst.  356 ;  Ortwein  vs.  Common- 
wealth, 76  Pa.  St.  414 :  Broivn  vs.  Commomcealth,  78  Pa.  St.  122. 


MORAL   INSANITY. 

The  impulses  hitherto  referred  to  have  been  of  two  kinds.  The  one, 
overwhelming  the  reason,  conscience,  and  judgment,  obliterates  or  ob- 
scures the  capacity  to  distinguish  between  right  and  wrong.  {Common- 
ivealth  vs.  Rogers,  Jr.,  7  Mete.  500 ;  Cunningham  vs.  State,  56  Miss.  269 ; 
People  vs.  S])ragne,  2  Park,  C.  R.  Cases,  43 ;  Eegma  vs.  Barton,  3  C.  C. 
277.)  The  other,  irrespective  of  its  influence  upon  this  same  capacity,  so 
subjugates  the  will  as  to  deprive  the  subject  of  the  power  of  self-control 
— the  freedom  of  moral  action.  This  latter  impulse  being  the  undoubted 
offspring  and  product  of  mental  derangement — of  intellectual  insanity — 
a  recognition  of  it  as  an  element  of  responsibility  does  not  involve  as  a 
necessary  consequence  an  acquiescence  in  the  theory  of  the  so-called 
^^  moral  or  emotional  insanity."  This  theory,  having  its  origin  in  a  sup- 
posed lesion  of  the  will,  apart  from  that  of  the  understanding,  in  the  pre- 
sumed existence  of  an  instinctive  and  abstract  rage  or  mania  withoiit 
delirium,  "  nn  emportement  maniaque  sans  delire,'''  was  extended  by  other 
theorists  to  the  discovery  and  description  of  a  disorder  called  "moral  in- 
sanity," of  which  the  symptoms  were  only  displayed  in  the  state  of  the 
feelings,  affections,  temper,  and  in  the  habits  and  conduct  of  the  indi- 
vidual, or  in  the  exercise  of  those  mental  faculties  which  are  termed  the 
active  and  moral  powers  of  the  mind.  In  this  alleged  disorder  it  was 
assumed  that  there  was  no  discoverable  illusion  or  hallucination,  or 


MENTAL  ItESPONSIBILITY  IN  CRIMINAL    CASES.  253 

any  symptom  characteristic  of  monomania  or  intellectual  insanity — in  a 
word,'  that  "  an  insanity  in  conduct "  existed  separately  and  distinct  from 
the  insanity  in  ideas.  (Prichard's  Forms  of  Ltsaiiifij,  sec.  v.)  Dr.  Mauds- 
lev,  reeog-nizing'  this  alleged  form  under  the  general  name  of  "  affective 
insanity  " — that  is,  insanity  without  delusion,  or  insanity  of  feeling  and 
action— subdivides  it  into  the  two  classes  of  impulhiive  and  moral  insan- 
ity ;  the  former  being  mental  disease  whereby  tlie  sufferer,  with(nit  i)as- 
si'on,  delusion,  or  motive,  is  driven  independently  of  the  will  by  blind 
instinctive  impulses ;  the  latter  a  disorder  of  the  mind  without  illusion, 
delusion,  or  hallucination,  the  symptoms  of  which  being  mainly  exhibited 
in  a  i)erver.sion  of  those  mental  faculties  which  are  usually  called  the  act- 
ive and  moral  powers.  {ResponsiMlifji  in  Monial  Disease,  chiv^.  y.)  Dr. 
Eay  and  others,  insisting  upon  the  existence  of  a  moral  mania  as  contra- 
distinguished from  the  intellectual  form,  distinguished  between  general 
moral  mania  and  partial  moral  manias,  the  latter  being  evidenced  by  spe- 
cific morbid  impulses  which  are  in  these  cases  presumably  the  exclusive 
and  essential  symptoms  of  the  existing  insanity :  such  as  kleptomania,  an 
irresistible  impulse  to  steal ;  pyromania,  an  ii-resistible  impulse  to  burn 
and  destroy,  erotomania  and  nymphomania,  irresistible  impulses  to 
.sexual  excess ;  homicidal  mania,  an  irresistilile  impulse  to  kill ;  suicidal 
mania,  an  irresistible  impulse  to  self-destruction.  (Ray's  Medical  Jiiris- 
jyrudence  of  Insanitu,  chap,  vii.)  As  in  the  opinion  of  the  medical  experts 
there  were  e"vidences  of  mental  derangement  in  the  case  of  Charles  P. 
Huntington,  who  was  tried  for  forgery  at  the  G-eneral  Sessions  of  the 
county  of  New  York  in  the  year  1856,  the  diseased  tendency  to  "  make 
paper,"  that  is,  forge  commercial  paper,  may  not  perhaps  be  considered 
an  addition  to  the  above  classifications.  (Trial  of  Charles  P.  Hunting- 
ton, Testimony  of  Willard  Parker,  M.D.,  p.  253.) 

It  is  obvious  that  these  theories,  the  "  excuse  of  an  irresistible  impulse 
coexisting  with  the  full  possession  of  reasoning  powers"  (Baron  Parke, 
Regina  vs.  Barton,  supra),  can  find  no  countenance  in  the  law  of  England, 
"which  does  not  admit  into  its  criterion  of  responsibility  the  element  of 
impulse,  even  though  that  impulse  be  the  undoubted  offspring  of  inteUect- 
nal  derangement.  A  recognition  no  more  ample  is  given  b}'  the  courts 
of  those  American  States  that  admit  an  impairment  by  disease  of  the 
freedom  of  the  will,  the  disease  being  presumably  a  form  of  intellectual 
insanity.  {Parsons  vs.  State,  supra.)  Some  few  cases  which  cannot  be 
considered  as  authorities  have  gone  a  step  beyond.  At  an  early  day  in 
Pennsylvania  Chief-Justice  Gil^son  affirmed  [Conunonwealtli  vs.  Mosler,  4 
Pa.  St.  26-4)  that  insanity  was  either  meutal  or  moral,  the  latter  consist- 
ing of  an  irresistible  impulse  to  kill  or  commit  some  other  offense.  The 
Supreme  Court  of  Connecticut,  speaking  through  Mr.  Justice  Carpenter, 
held  that  a  derangement  of  the  moral  faculties  is  in  itself  a  particular 
form  of  insanity,  which  is  divided  into  two  kinds,  general  and  partial ; 
the  former  consisting  in  a  general  exaltation,  perversion,  or  derangement 
•of  function  of  all  the  affective  or  moi-al  powers ;  the  latter  of  particular 
morbid  impulses,  such  as  kleptomania,  or  propensity  to  steal ;  pyromania, 
or  propensity  to  destroj'  by  fire;  and  homicidal  mania.  [Andersen  vs. 
State,  43  Conn.  514.)  So  also  the  Supreme  Court  of  Kentucky :  "  The 
common  law  progresses  with  all  other  science  with  wdiich  it  is  affiliated 
as  a  gTowing  and  consistent  whole.  And,  consequently,  as  the  science 
•of  man's  moral  nature  has  developed  the  phenomena  of  insane  affections, 


254  ^   SYSTEM  OF  LEGAL  MEDICINE. 

emotions,  and  passions,  which  either  nentralize  or  subjugate  the  will^ 
medical  jurisprudence  recognizes  this  morbid  and  overwhelming  influ- 
ence as  moral  insanity,  and  pronounces  it  as  exculpatory  as  the  other 
form  called  intellectual  insanity.  No  enlightened  jurist  now  doubts  the 
existence  of  such  a  type  of  moral,  contradistinguished  from  intellectual, 
insanity,  as  homicidal  mania,  or  morbid  and  uncontrollable  appetite  for 
man-killing,  and  pyromania,  or  the  like  passion  for  house-burning,  and 
kleptomania,  or  an  irresistible  inclination  to  steal.  In  each  of  these 
cases  and  others  of  a  kindred  character,  whether  the  unnatural  passion 
be  congenital  or  only  the  offspring  of  some  supereminent  cause,  moral 
unhingement  and  a  subjugated  and  subsidized  will  are  the  invariable 
characteristics.  This  is  disease,  and  the  man  thus  doomed  to  the  anarchy 
of  morbid  and  ungovernable  passions  is,  in  law  as  well  as  in  fact,  iusane ; 
and  to  the  extent  of  the  operation  of  that  blind  and  brutal  influence  he 
may  be  no  more  responsible  than  a  tiger  or  other  brute."  {Smith  vs. 
CommomveaUh,  1  Duv.  [Ky.]  224.) 

The  reproach  of  Lord  Chief-Justice  Cockburn  can  with  sufficient  rea- 
son be  addressed  to  courts  which  would  affirm,  as  matter  of  law,  that 
which  it  is  not  the  province  of  law  either  to  affirm  or  deny,  especially 
when  doctrines  most  dangerous  have  been  laid  down  dogmatically  in  the 
name  of  advanced  science.  Tlie  fact  of  the  existence  of  moral  and  emo- 
tional mania,  of  the  diseased  impulses  as  types  of  insanity  distinct  and 
apart  from  any  accompanying  intellectual  derangement,  are  questions  of 
mental  pathology,  and  as  such  do  not  come  within  a  consideration  of 
insanity  from  the  legal  point  of  view.  In  this  connection  it  suffices  to 
affirm  that  their  existence  is  not  an  admitted  fact  of  science,  but  a  the- 
ory, the  subject  even  at  the  present  day  of  dispute  and  controversy. 
("Moral  Insanity — What  is  It?"  by  J.  Workman,  M.D.,  American  Jour- 
nal of  Lmmify,  vol.  xxxix.,  p.  334;  "Intemperance  and  Insanity,"  by 
Dr.  Chipley,  American  Journal  of  Insanity,  vol.  xxiii.,  p.  1 ;  "  Report  of 
the  Annual  Meeting  of  the  Association  of  Medical  Superintendents  of 
American  Institutions  for  the  Insane,  held  on  the  16th  of  May,  1863," 
American  Journal  of  Insanity,  vol.  xx.,  p.  60  ;  Translation  by  Dr.  J.  Work- 
man of  "  Ulterior!  Considerationi  suU  Argomento  della  Cosi  detta  Pazzia 
Morale,"  by  Dr.  C.  Bonfigli,  American  Journal  of  Insanitj/,  vol.  xxxvi.,  pp. 
224,  476  ;  "  Kleptomania,"  by  Dr.  J.  C.  Bucknill,  Journal  of  Mental  Science, 
vol.  viii.,  July,  1862  ;  Casper's  HanJbooh  of  Forensic  Medicine,  vol.  iv.,  part 
vi.,  chap,  ii.,  sec.  75,  76,  88,  89,  91,  93.) 

The  problem  and  difficulty  presented  to  medical  jurisprudence  by  the 
theory  of  affective  or  moral  'insanity  would  not  lie  in  the  abstract  ques- 
tion as  to  its  existence,  which  is  one  of  fact  and  one  for  mental  science 
alone  to  decide,  but  in  the  proof  of  its  actual  existence  when  pleaded  as 
a  justification  in  any  particular  instance.  (Stephen's  General  View  of  the 
Criminal  Law  of  England,  chap,  ii.,  p.  95.)  This  was  elaborately  set  forth 
by  Mr.  Justice  Allen  in  his  charge  to  the  jury  in  the  case  of  WiUiam 
Speirs,  who  was  tried  at  Rome,  K  Y.,  in  the  year  1858,  for  having  will- 
fully set  fire  to  the  State  Lunatic  Asylum  at  Utica,  the  defense  being 
insanity  in  the  special  form  of  a  morbid  propensity  for  "  fire-raising." 
"  The  defense  was  made  to  rest  mainly  upon  the  ground  of  moral  insan- 
ity, so  caUed,  which  under  that  name  had  but  recently  found  a  place  in 
any  of  the  classifications  or  divisions  of  insanity.  That  the  moral  affec- 
tions might  be,  and  frequently  were,  perverted  or  impaired  by  the  same 


MILMJL   IlEi^rOXSlIULlTY   IX   CUIMIXAL    CASES.  2.").') 

diseases,  or  other  causes,  wliicli  affected  or  impaired  the  reasoning  fac- 
uUies  and  the  memory,  was  not  doul)ted.  But  'moral  insanity,'  as  a 
distinct  manifestation  apart  from  any  derangement  of  the  intellectual 
faculties  or  any  disease  affecting  the  nund,  had  not  been  and  could  not 
be  with  safety  recognized  by  the  law  as  exempting  its  subjects  frt>m  jiun- 
ishmcnt  for  their  unlawful  acts.  Certainly  this  cmUd  not  be  done  until 
science  should  be  able  to  do  what  it  has  not  yet  done — describe  its  cliar- 
acteristics  and  manif(\stations,  and  detine  its  evidences  and  the  rules  by 
which  its  existence  could  be  ascertained  and  known.  It  should  be  capa- 
ble of  being  distinguished  from  moral  depra\ity.  Men  of  science,  for 
the  convenience  of  investigation  and  discussion,  might  snbdi\'ide  and 
classify  these  subjects  as  they  pleased,  and  distinguish  their  divisions 
by  any  nomenclature  which  might  be  convenient,  and  no  harm  could 
ensue ;  but  when  courts  and  juries  were  called  upon  to  ajiply  the  princi- 
ples and  deductions  of  science  in  the  process  of  judicial  investigation,  it 
was  indispensable  that  their  tests  should  be  such  as  were  capable  of 
being  appreciated  and  judged  with  some  approximation  to  certainty ; 
that  is,  the  deductions  and  conclusions  of  science  which  are  to  control 
judicial  action  and  be  influential  in  the  administration  of  justice  should 
be  the  ascertained  results  and  consequences  of  facts  proved,  judged,  and 
applied,  according  to  the  well-established  principles  of  the  particidar  sci- 
ence involved.  Some  of  the  witnesses  had  spoken  of  a  moral  mania,  of 
which  an  individual  might  be  the  sul)ject,  and  by  which  he  might  be  im- 
pelled to  the  commission  of  crime  ;  but  juries  could  not,  with  any  safety, 
regard  a  maniacal  impulse  of  this  description  as  absohing  fi-om  the  con- 
sequences of  crime,  in  the  absence  of  any  eWdence  of  a  lesion  of  the 
intellect  and  reasoning  powers,  or  of  some  derangement  or  disease  affect- 
ing the  mind  and  judgment — and  for  the  best  of  all  reasons,  that  there 
could  not,  in  the  nature  of  things,  be  any  satisfactory  evidence  of  any 
disease  or  derangement  of  the  functions  of  the  individual  which  coidd 
convince  a  jury  that  the  act  was  not  tlie  deliberate  and  voluntary  act  of 
the  party,  his  mind  assenting  to  it.  The  existence  of  the  impidsive 
mania  could  oidy  be  proved  by  the  commission  of  the  acts  which  it  was 
sought  to  excuse,  which  would  be  no  evidence  at  all ;  and  the  jury  coidd 
never  know,  e^-en  should  it  be  conceded  that  such  a  '  moral  mania '  might 
and  did  exist,  whether  in  a  particidar  case  the  acts  were  the  results  of 
this  impulse  or  the  fruits  of  a  wicked  and  depraved  mind.  Courts  and 
juries,  in  the  attempt  to  determine  the  existence  of  '  moral  mania '  or 
ii-resistible  im})ulse,  apart  from  mental  disturbance  and  derangement,  as 
evidenced  by  the  well-known  symptoms  of  mental  disease,  as  an  excuse 
for  crime,  would  become  bewildered  and  lost  in  the  labyrinth  of  scien- 
tific niceties  and  fanciful  theories.  But  when  called  upon  to  consider 
the  subject  of  insanity,  regarded  as  a  derangement  of  the  intellect,  a 
mental  disease,  or  the  manifestations  of  disease  affecting  the  mind, 
whether  the  moral  powers  Avere  or  were  not  impaired  or  perverted,  they 
were  not  entirely  without  the  means  of  arriving  at  a  satisfactory  conclu- 
sion with  the  aid  of  intelligent  and  experienced  men  and  the  exercise  of 
their  good  judgment."  ("  The  Case  of  "\Villiam  %^eii"&,^^  American  Journal 
of  Insanitji,  vol.  xv.,  p.  200.) 

It  is  insisted,  however,  that  the  difficidty  presented  to  forensic  medi- 
cine does  not  end  with  the  disproof  or  refutation  of  the  theory  of  a 
purely  emotional  or  moral  insanity :  that  cases  occur  where  the  disorders 


25G  A   SYSTIJM  OF  LEGAL  MEDICINE. 

in  the  emotional  or  moral  natnre  are  the  predominant  symptoms,  the 
intellectnal  lesion  being-  masked  or  obscure,  these  sj'mptoms  marking 
the  earl,y  stage  of  what  will  eventually  prove  to  be  an  undoubted  case 
of  intellectual  insanity.  It  is  insisted,  further,  that  under  these  condi- 
tions a  crime  nuiy  be  committed,  the  product  of  cerebro-mental  disease. 
("  The  Moral  Phenomena  of  Insanity  and  Eccentricity,"  by  Thomas  Mayo, 
M.D.,  The  Medical  and  Psychological  Critic,  vol.  i.,  p.  173 ;  BuckniU  and 
Tuke,  Psijchological  Medicine,  p.  258.)  Of  this,  the  case  of  the  boy  Wil- 
liam Newton  Allnut,  tried  at  the  Central  Criminal  Court  for  the  murder 
of  his  gTandfather  by  poisoning,  furnishes  us,  according-  to  the  medical 
witnesses  in  that  case,  a  practical  example ;  the  accused  lieing-,  in  their 
opinion,  in  an  early  stage  of  insanity,  which  affected  his  nioi'al  sentiments 
and  interfered  with  his  notions  of  right  and  wrong,  but  which  did  not 
then  affect  his  intellect  in  any  marked  degree.  (Trial  of  William  Newton 
AUnut,  Testimony  of  Dr.  Densbury  and  Dr.  Conolly,  Loudon  Times,  De- 
cember 16,  1847.) 

The  difficulty  thus  presented  is  obvious  even  to  those  who  have  sug- 
gested it,  and  some  have  attempted  its  solution.  "  The  vicious  act  or 
crime  is,"  says  Dr.  Maudsley,  "  not  in  itself  proof  of  insanity ;  it  must, 
in  order  to  establish  moral  insanity,  be  traced  from  disease  through  a 
proper  train  of  symptoms,  just  as  the  acts  of  a  sane  man  are  deduced 
from  his  motives,  and  the  evidence  of  disease  Avill  be  found  in  the  entire 
history  of  the  case.  Wha,t  we  shall  often  observe  is  this,  that  after  some 
great  moral  shock,  or  some  severe  physical  disturbance,  in  a  person  who 
has  a  distinct  hereditary  predisposition  to  insanity,  there  has  been  a 
marked  change  of  character ;  he  becomes  '  much  different  from  the  man 
lie  was '  in  feelings,  temper,  habits,  and  conduct.  We  observe,  in  fact, 
that  after  a  sufficient  and  well-recognized  cause  of  mental  derangement 
— a  combination  of  predisposing  and  exciting  causes  which  are  daily  pro- 
ducing it — a  person  exhibits  symptoms  which  are  strangely  inconsistent 
with  his  previous  character,  but  which  are  consistent  with  moral  insanity. 
Or  it  may  appear  that  there  has  been  an  attack  of  paralysis  or  epilepsy, 
or  a  severe  fever,  and  that  the  change  of  character  and  the  symptoms  of 
moral  alienation  have  followed  one  of  these  physical  causes.  In  all  cases, 
as  Dr.  Prichard,  who  was  the  first  to  describe  the  disease,  has  remarked, 
there  has  been  an  alteration  in  the  temper  and  habits,  in  consequence  of 
disease  or  of  a  sufficient  cause  of  disease.  Perhaps  the  strongest  evidence 
of  the  nature  of  moral  insanity  as  a  disease  of  the  brain  is  furnished  by 
the  fact  that  its  symptoms  sometimes  precede  for  a  time  the  symptoms 
of  intellectual  derangement  in  a  severe  case  of  undoubted  insanity,  as, 
for  example,  a  ease  of  acute  mania,  or  of  general  paralysis,  or  of  senile 
dementia.  It  is  interesting,  indeed,  to  notice  that  at  least  one  of  Dr. 
Prichard's  cases,  on  Avhich  he  founded  his  description  of  the  disease,  was 
really  a  case  of  general  paralysis — a  disease  not  specially  recognized  in 
Ms  day,  but  the  best  known  now  of  all  the  forms  of  mental  derange- 
ment. Surely,  then,  when  a  person  is  subject  to  a  sufficient  cause  of  in- 
sanity, exhibits  thereupon  a  great  change  of  character,  and  finally  passes 
into  acute  mania  or  general  paralysis,  we  cannot  fairly  be  asked  to  rec- 
ognize the  adequate  cause  of  the  disease  and  the  intellectual  disorder  as 
disease,  and  at  the  same  time  to  deny  the  character  of  disease  to  the  in- 
termediate symptoms."     {Fcsponsihili'fj/  in  ]\[enfal  Pisease,  pp.  173, 174.) 


MENTAL  REsroxsiBir.iTY  IS  ciuminal  cases.  257 

Aceortlini^'  to  Dr.  Rtiy,  if  inoriil  insaiiily  Ix'  iileaded  in  dofen.so,  proof 
of  the  fact  must  be  found  in  the  antecedents  of  the  prisonei-,  tlie  manner 
of  committing'  the  crime,  his  mental  or  bodily  condition,  all  the  circum- 
stances, in  fact,  connected  with  the  act.  {''■  An  ]i]xamination  of  the  Objec- 
tions to  the  Doctrine  of  'Moral  Insanity,'"  by  Isaac;  Kay,  M.D.,  yi;><('/-/<;'«« 
JoiirndJ  of  Insdiiiff/,  vol.  xviii.,  p.  112.) 

Dr.  Take,  adnuttinn'  that  no  absolute  rule  can  be  laid  down  to  diffei'- 
entiate  moral  insanity  from  moral  depraA'ity,  insists  tliat  each  case  nuist 
be  decided  in  relation  to  the  individual  himself,  his  antecedents,  his  edu- 
cation, surrounding's,  and  social  status,  the  nature  of  certain  acts,  and 
the  mode  in  which  they  are  j^erformed,  along  with  other  circumstances 
fairly  raising-  the  suspicion  that  they  are  not  under  his  control.  In  no 
other  form  of  insanity  is  it  so  necessarj^  to  study  the  individual,  his 
natural  character,  his  organization,  and  his  previous  diseases.  ("Moral 
or  Emotional  Insanity,"  D.  Hack  Tuke,  Journal  of  Mental  Science,  vol. 
xxxi.,  p.  174.) 

Emotional  insanity  as  a  defense  has  generally  been  presented  under 
the  form  of  the  so-called  ''  mania  transitoria,"  an  instantaneous  tempo- 
rary madness  which  begins  ''in  the  eve  of  the  criminal  act  and  ends 
when  it  is  consummated."  (Depue,  J.,  8U(te  vs.  Grave,  5  N.  J.  L.  J.  54.) 
The  acceptance  of  this  theory  by  jui'ies  as  an  exculpation  of  the  accused 
may  be  regarded  in  certain  cases  at  least  as  a  proof  of  their  sympathy 
with  him,  and  of  their  consequent  determiuation  to  acquit.  ("  The  C'ase 
of  People  vs.  Eratus  F.  Pierce,-'  Anio'icaii  Journal  of  Insaniiij,  vol.  xxviii., 
p.  399 ;  Cole's  Trial,  7  Abb.  Pr.,  N.  S.,  321.) 

The  utterances  of  the  law  on  this  subject,  so  replete  with  difficulty, 
cannot  receive  a  complete  acquiescence  on  the  part  of  the  jurist.  An 
unwillingness  to  admit  that  the  facts  of  insanity  were  to  be  learned  from 
science  and  learned  opinion,  rather  than  from  ordinary  evidence,  like 
an  ordinary  fact  (Lord  Chancellor  Westbury,  Debate  of  March  11,  1862, 
Hansard's  Debates,  third  series,  vol.  clxv.,  p.  1297),  has,  as  an  error,  its 
j)arallel  in  the  intrusion  made  by  the  law  into  the  domain  of  mental 
pathology  itself.  The  writings  of  the  earliest  authorities  and  some  of 
the  judicial  utterances  of  later  days,  by  their  attempted  classifications  of 
mental  disease,  and  dogmatism  as  to  its  essential  nature  and  character- 
istics, have,  under  the  name  of  the  law,  perpetuated  or  given  longer  life 
to  scientific  errors  or  the  imperfect  science  of  the  time,  as  witness  the 
description  drawn  between  madness  and  lunacy,  the  imputing  to  insanity 
delusion  as  its  essential  and  necessary  characteristic,  and  the  drawing  of 
fixed  legal  consequences  from  the  fact  of  delusion  itself.  It  is  submitted 
that  with  the  particular  foi'ms  of  insanity  and  its  essential  characteris- 
tics as  a  disease  the  law  has  nothing  Avhatever  to  do.  The  effects  of  the 
various  manias,  of  epilepsy,  the  prol)aT)le  limit  and  effect  of  delusions, 
the  relation  of  the  insane  impulses  to  the  human  will,  the  question  as  to 
the  existence  and  nature  of  an  insanity  purely  emotional  and  moral,  are, 
and  must  remain,  facts  of  mental  pathology  to  be  proved  or  disproved  as 
facts,  and  not  to  be  dogmatically  affirmed  or  denied,  and  to  be  viewed 
only  in  relation  to  the  legal  question  of  responsibility.  As  to  this  it 
may  fairly  be  asked  whether  the  action  of  the  House  of  Lords  in  relation 
to  ^IcNaghten's  Case  has  not  justificnl  the  apprehensions  of  Mr.  Justice 
Maule,  in  ULsettling  rather  than  settling,  the  law  by  the  suggestion  of 


258  ^   STSTEM  OF  LEGAL  MEDLCINE. 

doubts  rather  than  the  solution  of  them,  thus  a,ffording  matter  for  bit- 
terest controversy  between  the  professions  of  law  and  medicine,  a  con- 
troversy that  extends  even  to  the  present  time.  A  complete  and  unas- 
sailable canon  of  responsibility  is  perhaps  yet  to  be  formulated,  but  its 
establishment  cannot  lead  beyond  the  threshold  of  the  difficulties  of  fact 
that  must  always  confront  the  human  tribunal. 


APHASIA  AND  OTHEE  AFFECTIONS  OF  SPEECH. 

BY 

CHAKLES  K.  MILLS,  M.D. 
HISTORY    AXD    LITERATURE. 

The  medico-legal  aspects  of  aphasia  and  other  affections  of  speech 
have  not  escaped  investigation  and  discussion,  but  they  have  received 
little  attention  from  English  and  American  wiiters,  and,  compared  with 
the  immense  literature  of  the  general  subject  of  aphasia,  but  Httle  fi'om 
writers  of  other  nations.  Much  of  the  work  published  has  been  in  the 
nature  of  records,  with  comments  on  particular  cases  which  have  come 
before  a  coiu't  or  other  tribunal ;  and  in  few,  if  any,  of  these  contributions 
has  any  systematic  effort  been  made  to  classify  for  medical  purposes  the 
now  well-recognized  forms  of  aphasia.  In  papers  deahng  with  the  gen- 
eral phenomena  and  mechanism  of  speech,  imj)oriant  medico-legal  points 
are  developed  in  a  casual  and  incidental  manner,  as  in  the  wiitiugs  of 
J.  Hugldings  Jackson,*  Charcot,t  Lichtheim,|  and  Ross;§  and  to  some 
of  these  references  will  be  made  in  the  course  of  tliis  article.  In  the  sec- 
ond edition  of  Bateman's  treatise  on  aphasia,] |  a  new  chapter  on  the 
jurisprudence  of  aphasia  is  introduced,  in  which  some  original  observa- 
tions are  given,  and  references  are  made  to  the  work  of  French  and  Ger- 
man authors. 

Batemanff  cites  some  cases  of  interest.  In  1743,  for  example,  a  resi- 
dent of  Miinden,  Hanover,  applied  to  the  government  for  permission  to 
make  a  "v^'ill  by  signs  in  favor  of  his  wife,  and  the  court  acknowledged 
the  validity  of  the  act.  Another  aphasie  for  five  years  discharged  the 
functions  of  mayor  and  municipal  councilor,  l)y  wi'iting  his  name  to  nec- 
essary documents  with  his  left  hand.  In  the  same  way  he  also  wi-ote  a 
holographic  will,  which  was  sustained.  These  and  other  cases  are  refeired 
to  by  Legrand  du  8aulle.  Bateman  refers  to  several  cases  in  which  the 
wills  of  deaf-mutes  were  recognized  as  valid  by  the  court  because  it  was 
proved  that  tliey  understood  the  contents  of  the  will,  either  through  gest- 
ure and  pantomime  alone,  or  by  these  and  wi-itten  lang-uage  combined. 
He  also  records  the  case  of  a  man,  sixty-three  years  old,  who  was  engaged 

*  Huglilings  Jackson,  Brain,  October,  1S78.  and  Jnly  and  October,  1879. 

t  Charcot,  Le  Procf.  MaL,  1884.  and  Medical  Pres^  and  Circular,  London,  1884. 

t  Lichtheim,  Brain,  Jannary,  1885. 

§  Ross.  Jjiltasia,  etc.,  London,  1887;  New  York,  1890. 

II  Bateman,  Aphasia,  etc.,  London,  1890. 

U  Ibid. 

259 


260  ^   SYSTEM  OF  LEGAL  MEDICINE. 

to  be  married  and  was  suddenly  seized  with  right  hemiplegia  and  apha- 
sia, and  wished  to  make  a  will  in  favor  of  the  lady  whom  he  intended  to 
make  his  wife.  The  document  was  wi-itten  by  one  of  his  medical  attend- 
ants. The  testator's  mark  was  made  and  the  will  attested  by  witnesses. 
He  communicated  his  wishes  by  making  signs  for  wiiting  materials.  Hi& 
wishes  were  then  interpreted  by  means  of  signs  and  written  down  on  a 
card.  He  held  up  his  hand,  extended  his  five  fingers,  and  he  was  asked 
if  he  meant  "  thousand  " ;  he  bowed  assent.  He  then  closed  his  hand  and 
opened  it  the  same  way,  implying  ten ;  this  operation  was  repeated  until 
it  amounted  to  thirty,  then  he  dropped  his  arm  down.  Testator  was 
then  asked  whether  he  wished  Miss  R.  to  have  £30,000,  and  he  nodded 
his  head.  When  asked  if  Miss  R.  was  to  have  this  sum  absolutely,  he 
signified  dissent ;  but  on  being  asked  if  it  was  to  be  hers  for  life  and 
afterward  to  revert  to  his  family,  he  bowed  his  head.  Unfortunately  the 
testator's  mark  was  made  in  the  middle  of  the  card  instead  of  at  the 
bottom  or  foot,  and  so  did  not  satisfy  the  provisions  of  the  statutes  relat- 
ing to  wills,  and  the  testament  was  therefore  refused  probate. 

In  Dumas's  Count  of  Monte-Cliristo  is  an  interview  with  a  motor  aphasic 
which  might  have  answered  as  testimony  in  court  in  a  case  in  which  the 
question  was  that  of  testamentary  capacity.  The  old  Bonapartist,  Noii'- 
tier,  paralyzed  and  profoundly  aphasic,  angered  at  his  son  and  daughter- 
in-law,  determines  to  change  his  will.  His  son,  his  granddaughter,  and 
his  old  servant  could  undei'stand  and  communicate  with  him  through  an 
arranged  system  of  signs — by  his  closing  his  eyes  for  "  yes,"  by  winking 
them  when  he  meant  "  no,"  and  when  he  had  some  desire  or  feeling  to 
express,  by  looking  upward.  He  signifies  his  desire  for  a  notary  by 
indicating  to  his  granddaughter,  who  recites  to  him  all  the  letters  of  the 
alphabet,  that  he  wishes  "  n "  and  "  o "  in  succession ;  then  with  a  dic- 
tionary he  picks  out  the  word  ''  notary."  Two  notaries  are  brought  and 
read  the  formal  copy  of  the  will,  and  then  test  Noirtier  by  much  the 
same  method  as  Bateman  relates  was  employed  in  the  case  above  cited. 
Several  sums  are  named  before  the  aphasic,  who  signs  "  no  "  until  the 
question  is  asked,  ''  Do  you  possess  900,000  francs  ? "  In  answer  to  this 
he  closes  his  eyes  in  assent.  He  finally  succeeds  in  making  a  will,  of  the 
validity  of  which  the  notaries  are  thoroughlj^  satisfied,  although  other 
characters  in  the  story  are  not  equally  satisfied  with  its  contents. 

At  the  meeting  of  the  British  Medical  Association,  1889,*  Dr.  Drys- 
dale,  of  London,  cited  the  case  of  a  celebrated  civil  engineer  who  had 
right  motor  paralysis  and  aphasia,  but  who  wrote  his  own  checks,  copy- 
ing them  from  a  former  signature  of  his  own,  and  who  for  many  years 
was  a  senior  partner  of  the  fii-m.  His  partners,  however,  did  all  the 
work.  In  this  case  the  gentleman  retained  enough  intelligence  to  play 
whist  with  the  cards  spread  out  before  him,  and  left  a  ■v^^ll  which  was 
not  contested.  Professor  Gairdner,  at  a  former  meeting  of  the  British 
Medical  Association,  had  mentioned  the  case  of  a  Scottish  judge  affected 
"with  aphasia  who  had  continued  in  office  for  some  years,  and  sat  on  the 
bench  while  suffering  from  a  form  of  this  malady. 

Legi'and  du  Saullet  has  extensively  discussed  the  subject  of  aphasia 

*  New  York  Medical  Becord,  September  28,  1889,  p.  360. 

t  Legi'and  du  Haulle,  Gazette  dcs  Hdjritnnx,  June  and  July,  1868 ;  and  ihid.,  vol.  Iv., 
1882.  In  this  series  of  lectures  other  references  are  as  follows :  Ch.  Sazie,  Trouhles 
Intellectuels  dans  I'Aphasie,  Paris,  1879 ;  Finance,  Etat  Mcntalc  des  Apliasiques :  Con- 


APHASIA   AND    OTHER  AFFECTIONS   OF  SPEECH.  2G1 

and  apliasies  c'onsidcn'd  fi'oiu  the  modico-lcji'al  and  other  points  of  view. 
He  holds  that  when  the  lesion  of  aphasia  is  eonfined  exclusively  to  the 
third  left  frontal  convolution,  intellectual  disturbance  is  slig-lit ;  but 
according:  as  it  has  extended  to  the  motor  zone,  or  to  the  prefrontal 
region,  will  })aralysis  or  disorders  of  tlie  intelligence  appear ;  also  that 
most  aphasics  have  a  certain  measure  of  dementia  as  well  as  of  paralj^sis, 
but  that  the  intellectual  disorder  observed  in  aphasics  is  most  varialde, 
sometimes  not  interferinii'  with  the  important  events  of  life,  at  others  so 
wrecking-  tlie  intellectual  faculties  as  to  cause  mental  incapacity  ami  irre- 
sponsibility. Among'  aphasics  impatience  and  anger  are  common ;  their 
moods  are  very  changeable  ;  want  of  attention  is  one  of  their  most  marked 
traits ;  memor}^  and  recollection  are  less  alert,  some  aphasics  exhibiting 
decided  loss  of  memory.  He  insists  that  aphasia  is  compatible  mtli  in- 
telligence, but  tliat  this  is  always  more  or  less  weakened  by  the  loss  of 
language.  If  the  brain  lesions  are  extended  and  multiple,  pronounced 
weakening  and  even  abolition  of  memory  nuiy  be  oliserved.  Incoherence 
of  ideas  when  present  is  not  by  any  meaiis  on  a  2)ar  with  incoherence  of 
language.  To  lesions  of  the  prefrontal  regions  he  relates  the  loss  of 
memory  and  attention,  the  incoherence,  hallucinations,  and  delirium — 
probably  only  a  partial  truth.  He  speaks  of  hallucinations  as  frecjuent 
among  aphasics,  the  most  common  being  those  of  hearing  and  sight; 
sometimes  these  hallucinations  are  of  a  character  that  may  lead  to  crime, 
or  may  make  the  aphasic  suspicious  of  others.  He  admits  three  cate- 
gories of  aphasics — those  in  whom  intelligence  is  intact,  but  slightly 
touched ;  those  in  whom  it  is  manifestly  changed :  and  those  in  whom  it 
is  entirely  aliolished.  A  physician  called  to  give  an  opinion  on  an  apha- 
sic should  give  attention  to  the  smallest  particulars.  He  has  need 
also  to  use  all  his  care  and  knowledge  in  scrupulousl}^  re^ie"\^dng  every 
one  of  the  different  forms  of  language  emploj-ed  by  an  aphasic.  It  is 
always  well  to  make  the  patient  count,  to  ask  his  age,  to  test  him  with 
money,  etc. 

Gallard,*  in  a  volume  of  clinical  lectures  delivered  at  La  Pitie,  has 
one  chapter  on  aphasia  and  aphasics  discussed  from  the  medico-legal 
point  of  view.  His  conclusions  with  reference  to  the  interdiction  of 
aphasics  are :  (1)  If  the  intelligence  of  the  aphasic  is  completely  obliter- 
ated, or  if  in  preserving  his  lucidity  he  cannot  manifest  it  by  "vndtteu 
language,  pantomime,  or  speech,  he  should  be  interdicted ;  (2)  if  the  in- 
telligence of  the  aphasic,  not  being  completely  alienated,  has  not  all  its 
l)rightness,  and  can  onl}^  be  incompletely  manifested,  he  should  be  pro- 
vided with  a  judicial  counsel ;  (8)  if  the  aphasic  possesses  his  intelligence, 
and  if  he  can  manifest  it  sulTficiently,  whether  by  word,  by  ^^Titing,  or  by 
signs,  he  has  no  need  of  judicial  protection,  and  should  be  free  to  man- 
age himself  and  his  affairs. 

The  Parish  will  case  is  perhaps  the  most  famous  American  medico- 
legal case  in  which  the  mental  power  of  an  aphasic  was  the  uuiin  point 
at  issue.     Henry  Parish  made  his  first  will  when  fifty-four  years  of  age, 

sidrriffioiis  Mrdico-Lnjalcs,  Paris,  1S7S ;  Legrand  du  SaiiUe,  Ftmlc  Mcdico-Li'gide  siir 
VI)t(cr(lictk»i  dcs  Aliciics  ct  siir  Ic  Coiificil  Jiidicidirc,  Paris,  1881,  p.  212;  J.  Lefort, 
"Reiuarqiies  siir  I'lnterdiction  des  Aphasiques,"  BidJvtin  dc  la  Sovietc  de  Mcdccinc  do 
France. 

*  Gallavd,  CJhnqitc  Mcdiadc  dc  La  PUic ;  analyzed  iu  Lc  Journal  do  Mcdccinc  ct  de 
Cliirurgic  Pratiipies,  vol.  xlviii.,  pp.  377-380. 


262  A  SYSTEM  OF  LEGAL  MEDLCINE. 

and  tlie  next  year  liad  a  slight  apoplectic  attack,  from  Avliicli  he  soon 
recovered.  Seven  years  after  making  his  will  he  had  another  severe 
apoplexy,  "which  left  him  for  the  rest  of  his  life,  about  seven  j^ears  in 
all,  paralyzed  in  his  right  limbs  and  v^ith  the  power  of  articulation  lost. 
After  this  second  seizure  he  also  had  at  intervals  epileptic  fits.  The 
codicils  to  his  will  were  contested.  The  first  was  made  about  six  weeks 
and  executed  about  five  months  after  the  severe  apoplectic  attack ;  about 
four  years  later  a  second  codicil,  and  about  five  yea,rs  after  this  a  third, 
were  made.  The  siuTogate  admitted  the  first  codicil  and  excluded  the 
others.  The  Supreme  Court  and  the  Court  of  Appeals  decided  against 
all  three.  The  trial  of  this  case  was  a  notable  one  and  eminent  physi- 
cians were  employed  on  both  sides.  Dr.  Isaac  Ray,  who  was  one  of  the 
medical  experts,  testified  in  opposition  to  Mr.  Parish's  testamentary  capac- 
ity, and  has  contributed  a  valuable  paper  on  the  case.*  " 

The  Beven  case  is  another  of  interest,  reported  by  Dr.  C.  H.  Hughes,  t 
Mr.  Beven  had  been  stricken  with  right  hemiplegia  and  aphasia,  probably 
due  to  embolism,  as  he  had  a  cardiac- valvular  lesion.  He  became  defend- 
ant in  a  suit  for  the  recovery  of  money  on  a  deed  of  trust  signed  by  himself 
with  his  left  hand  when  he  was  aphasic,  four  months  after  his  first  apo- 
plectic seizure,  in  1873.  Dr.  Hughes,  three  years  after  the  attack,  found 
that  he  was  suffering  from  incomplete  paralysis  of  motion  on  the  right 
side  and  general  angesthesia;  that  he  fully  understood  oral  signs,  and 
written  ones  tardily  and  imperfectly;  that  he  recognized  the  doctor's 
name  and  wi*ote  down  his  own  name  and  that  of  his  attorney  and  of  the 
doctor ;  tliat  he  either  had  or  feigned  defective  vision,  and  also  impaired 
hearing  in  the  left  ear.  He  had  had  three  paralytic  strokes  altogether, 
but  had  grown  steadily  better.  Dr.  Hughes  anah'zed  the  various  facts 
which  were  brought  forward  as  evidences  of  his  insanity,  and  decided  in 
favor  of  his  competency.  Dr.  Hughes  %  has  also  written  a  paper  on  the 
medico-legal  aspect  of  cerebral  localization  and  aphasia.  This  article 
reviews  the  varieties  of  aphasia,  with  some  consideration  of  the  lesions 
causing  them,  and  also  considers  to  some  extent  the  effect  of  simple  and 
complicated  aphasia  on  the  judging,  comparing,  expressing,  and  other 
faculties  of  the  mind,  citing  various-  authorities  in  support  of  his  posi- 
tions. 

The  Fillmore  will  case,  reported  by  Dr.  Landon  C.  Grray,§  has  at- 
tained considerable  celebrity  in  this  country,  both  because  of  its  in- 
trinsic interest  and  of  the  distinguished  position  of  the  parties  con- 
cerned. Mrs.  Caroline  S.  Fillmore,  widow  of  the  ex-President  of  the 
United  States,  in  1877,  three  years  after  the  latter's  death,  began  to  show 
changes  in  her  character,  soon  becoming  coarse,  profane,  suspicious,  and 
delusional.  She  was  stricken  with  hemiplegia.  She  made  two  wills,  the 
first  eighteen  months  after  the  changes  in  her  character  were  first  noted, 
and  nine  months  before  the  paralysis ;  the  second  will  or  codicil  was 
made  five  months  before  the  stroke.  She  developed  a  form  of  aphasia 
and  slio"vsTd  not  only  this  speech  disturbance,  but  a  combination  of  symp- 
toms of  general  mental  impairment.  Dr.  Gray  and  others  testified  that 
she  was  insane  and  incompetent. 

*  Ray,  Contributions  to  Mental  Patlioloffij. 

t  Hughes,  American  Journal  of  Iiinanilu,  vol.  xxxv.,  January,  1879,  p.  410. 

%  Hughes,  Alienist  and  Neurologist,  vol.  i.,  April  aud  July,  1880. 

iJ  Gray,  Aiiicrictiii  Journal  of  Xciii'olof/n  (did  rsijchiainj,  vol.  iii.,  p.  549. 


APHASIA   AND   OTHER  AFFECTIONS  OF  SPEECH.  203 

Ray,*  ill  liis  text-hook,  as  well  as  in  the  monograph  on  the  Parish 
case,  has  given  some  .-ittention  to  the  medieal  jurisprudence  of  aphasia, 
relating  several  interesting  eases. 

Diller  t  has  also  discussed  the  medieo-legal  aspects  of  aphasia,  and  gives 
notes  of  two  cases.  One  was  a  retired  physicdan,  sixty  years  old,  who  had 
a  hemiplegic  and  aphasic  attack,  after  which  he  conducted  a  large  busi- 
ness. An  effort  was  made  to  break  his  will  on  the  grounds  that  he  had 
progressively  deteriorated  mentally  and  i)hysieally,  and  that  his  will  Avas 
made  a  few  months  l)efore  his  death,  when  he  was  technically  insane 
and  incompetent.  A  will  which  had  l)een  nuide  some  years  before  his 
attack  of  aphasia,  and  wlji('h  almost  tallied  with  the  contested  wiU,  was 
sprung  in  court  and  caused  a  hast}'  termination  of  the  proceedings.  The 
second  was  a  case  of  right  hemiplegia  and  almost  complete  motor 
iiphasia  in  a  lady  of  sixty-five  years.  She  comprehended  and  expressed 
clearh'  enough  certain  ideas,  and  just  as  clearly  failed  to  express  certain 
others.  He  finally  concluded  that  she  was  incompetent  to  enter  into 
<3ivil  contracts  and  in  a  technical  sense  insane,  but  was  aljle  to  delegate 
to  her  children  power  of  attorney.  He  believed  tliat  she  would  be  able 
to  give  intelligent  assent  to  any  single  business  proposition,  but  that  she 
was  incompetent  to  receive  and  pay  out  money  constantly,  as  her  busi- 
ness required.  My  own  experience  mth  other  cases  accords  with  this 
conclusion.  Diller  holds  in  considering  the  medico-legal  problems  that 
may  arise  in  any  given  case  of  aphasia  that  it  is  only  necessarj'  to  deter- 
mine, first,  whether  the  person  is  sane ;  second,  whether  ideas  may  be  con- 
veyed to  him ;  and  third,  whether  he  can  convey  his  ideas  to  others. 

Clark  X  has  recorded  a  case  in  which  the  question  was  Avliether  a  hemi- 
plegic who  also  suffered  with  aphasia  was  competent  to  execute  a  will. 
After  his  attack  he  had  recovered  largely  and  had  gone  on  with  his  busi- 
ness. He  holds  that  it  would  not  do  to  declare  a  man  incompetent  simply 
because  of  his  aphasia. 

I\IEDICO-LEGAL   QUESTIONS  WHICH  IMAY  ARISE  IN  CONNECTION  WITH 

APHASICS. 

It  will  be  seen  from  this  hasty  glance  at  the  meager  literature  of  the 
subject  that  the  medico-legal  questions  which  may  arise  in  connection 
with  the  study  of  apliasics  are  somewhat  immerous,  although  all  are  by 
no  means  embraced  in  this  review.  They  include  many  of  those  which 
the  insane  present  for  solution,  but  also  others  especially  belonging  to 
aphasia.  At  the  outset  it  should  be  borne  in  mind  that  we  are  not  deal- 
ing with  some  clearly  defined  entity  called  "  aphasia."  It  is  not  possible 
to  fix  upon  any  general  standard  of  capacity  or  responsibility  for  one 
suffering  from  an  affection  simply  labeled  ''aphasia."  Even  correctly 
labeling  an  individual  as  insane  does  not  decide  as  to  his  riglit  to  have 
certain  privileges,  or  his  capacity  to  do  or  not  to  do  certain  acts,  as,  for 
example,  to  have  his  perscnml  liberty  or  the  control  of  his  estate,  to  get 
married,  or  to  make  a  will.  In  a  pi-actical  as  well  as  a  philosophical 
.sense,  questions  of  sanity  and  insanity  are  relative,  and  so  likewise  are 

*  Rfvy,  Medical  Jurisprudence  of  Inscniifi/. 

t  Diller,  Jour)i(d  of  Nerrous  aud  Moifal  Disease,  J\[ay,  1804,  p.  292. 

t  Clai-k.  American  Journal  of  lusanitii,  vol.  xlix.,  1 892-93,  p.  291. 


2G4  ^   SYSTEM  OF  LEGAL   MEDICINE. 

tliose  presented  by  apliasics.  They  will  depend  not  only  on  the  form  of 
the  disorder,  but  also  npon  its  degree  and  special  characteristics  in  a  par- 
ticular case. 

"  The  affections  of  speech  met  with  are  very  different  in  degree  and 
kind,"  says  Hughlings  Jackson,*  "for  the  simple  reason  that  the  exact 
position  of  disease  of  the  brain  and  its  gravity  differ  in  different  cases ; 
different  amounts  of  nervous  arrangements  in  different  portions  are 
destroyed  with  different  rapidity  in  different  persons.  There  is,  then, 
no  single,  well-defined  '  entity ' — loss  of  speech  or  aphasia — and  thus  to 
state  the  matter  for  a  practical  purpose,  such  a  question  as,  '  Can  an 
aphasic  make  a  will  ? '  cannot  be  answered  any  more  than  the  question, 
'  Will  a  piece  of  string  reach  across  this  room  ? '  can  be  answered.  The 
question  should  be,  '  Can  this  or  that  aphasic  person  make  a  will  ? ' " 

These  medico-legal  questions  may  be  either  criminal  or  civil,  although 
they  are  much  more  frequently  the  latter.  Legrand  du  Saulle  says  truly 
that  it  is  rare  for  aphasics  to  be  implicated  in  major  crimes,  being  to  a 
certain  extent  saved  from  them  by  their  habitual  infirmity ;  but  aphasics 
are  much  given  to  impatience  and  anger,  and  their  moods  are  uncertain 
and  changeable  and  occasionally  dangerous.  They  have  been  charged 
with  thefts,  and  have  been  imphcated  in  other  crimes.  One  remarkable 
case  is  referred  to  by  Legrand  du  Saulle.  An  aphasic  and  hemiplegic 
was  charged  with  killing  his  wife,  and  the  case  had  not  only  this  crimi- 
nal aspect,  but  later  a  civil  question,  that  of  the  disposal  of  his  and  of 
his  wife's  property,  arose.  The  parties  had  been  married  withoiit  a  con- 
tract, and  had  no  childi-en,  and  each  had  left  to  the  survivor  the  whole 
of  his  or  her  property.  Attempts  were  made  to  nulhfy  the  donation  of 
the  wife  on  account  of  ingratitude,  as  shown  by  the  assassination,  but 
against  this  it  was  urged  that  as  the  man  had  been  pronounced  irre- 
sponsible he  could  not  be  an  ingrate.  In  the  end,  however,  the  donation 
was  annulled  and  went  to  the  wife's  heirs. 

Evidently  whether  or  not  an  aphasic  should  be  exonerated  from  the 
consecpiences  of  a  crime  is  a  vital  matter,  and  in  some  cases  the  question 
should  be  decided  on  the  same  principles  that  would  govern  the  decision 
in  a  case  of  alleged  insanity ;  but  these  might  not  always  suffice,  and  the 
presence  of  the  aphasia,  and  its  form,  might  need  to  be  particularly  con- 
sidered in  arriving  at  a  correct  conclusion.  Many  aphasics  suffer  to  a 
greater  or  less  extent  from  various  special  forms  of  mental  diseases,  the 
degree  of  which  may  be  dependent  somewhat  on  the  location  of  the  lesion 
causing  the  speech  disturbance,  or  on  the  extent  to  which  the  aphasic 
lesion  has  extended  beyond  the  speech  centers,  or,  again,  it  may  be  en- 
tirely independent  of  the  aphasia.  The  lesion  which  causes  aphasia,  as 
is  well  known,  in  addition  usually  jDroduces  a  certain  and  it  may  be  a 
large  degree  of  paralysis,  and  less  frequently  also  various  sensory  dis- 
orders. The  greater  the  accompanying  disease,  even  though  it  be  of  a 
physical  type,  the  more  likely  it  is  that  the  mentality  of  the  patient  will 
suffer,  although  this  statement  must  be  qualified  somewhat  by  the  direc- 
tion which  the  lesion  has  taken.  M.  Sazie  tells  of  an  aphasic  who  had 
angesthesia  of  his  limbs,  and  who  believed  that  his  legs  had  been  ampu- 
tated ;  and  Legrand  du  Saulle  speaks  of  monomania,  melancholia,  hypo- 
chondria, and  of  impulses  to  drunkenness,  suicide,  or  even  homicide, 

*  Hughlings  Jackson,  Brain,  October,  1878,  p.  314. 


APHASIA  AND   OTHER  AFFECTIOXS   OF  SPEECH.  205 

among  apliasies.  Every  one  who  lias  had  much  experience  with  apliasics 
can  recall  such  cases,  but  we  must  remember  that  these  are  disorders 
occurring*  among  aphasics,  not  a  part  of  the  aphasia.  Recognizing  the 
importance  of  such  facts  as  these,  and  remembering  also  that  aphasics 
who  are  not  in  any  just  sense  insane  are  often  greatly  misunderstood,  it 
follows  that  the  conunittal  of  an  aphasic  to  an  insane  asylum  may  some- 
times be  a  serious  question  for  decision,  and  might  eventually  lead  to  a 
criminal  or  civil  suit. 

Kussmaul*  refers  to  the  fact  that  the  word-deaf,  possessing  at  tLe 
same  time  ability  to  express  themselves  in  words,  but  misj^lacing  and 
often  distorting  them,  leave  the  impression  that  they  are  crazed ;  and  he 
warns  the  observer  to  avoid  this  error,  and  also  the  greater  one  of  re- 
garding the  patient  as  both  deaf  and  demented.  He  cites  several  inter- 
esting cases — one  reported  by  Baillarger,  who  demonstrated  that  a 
woman  who  had  been  regarded  as  both  deaf  and  demented  was  really 
neither  one  nor  the  other ;  and  another  of  a  paraphasic  patient  of  Wer- 
nicke's, at  fii"st  supposed  to  be  deaf  and  crazy.  xVn  interesting  case  of 
aphasia  compheated  with  insanity  has  been  reported  by  Bancroft,  t 

Among  the  ei^il  questions  which  arise  in  connection  "udth  aphasics, 
perhaps  the  first  in  importance  is  that  of  testamentary  capacity,  and  such 
allied  questions  as  their  competency  to  make  deeds  of  trust  or  convey- 
ance, to  sign  23owers  of  attorney,  promissory  notes,  due  bills  or  checks, 
to  make  contracts,  or  to  manage  any  business  oi'diuarily  invohing  speak- 
ing or  %\Titing.  The  marriage  of  aphasics  may  have  to  be  considered. 
According  to  French  law — and  the  laws  of  otlier  nations  are  much  the 
same — dementia  is  the  only  thing  that  interdicts  marriage.  Aphasia  is 
not  suffi(;ieut  to  prevent  it.  Signs  are  recognized  as  available  to  signify 
consent ;  but  it  may  be  necessary  to  decide  as  to  the  true  signification  of 
the  pantomime  and  gestm-es  employed  by  the  aphasic.  The  question  is, 
whether  the  husband  or  wife  at  the  time  of  the  marriage  had  a  sufficient 
degree  of  intelligence  to  realize  the  act,  and  whether  it  was  of  his  or  her 
own  will.  An  interesting  case  is  given  by  Legrand  du  Saulle  of  an  aged 
aphasic  and  hemiplegio  mdow  who,  having  fallen  out  with  her  daughter, 
contracted  a  second  marriage  against  the  wishes  of  her  family.  I  once 
testified  before  a  register  of  wills  regarding  a  man  whom  I  had  seen  in 
consultation  several  weeks  before  his  death.  This  man  had  lived  for 
many  years  "v^ith  a  woman  who  was  not  his  wife,  but  by  whom  he  had 
several  childi-eu.  By  many  he  was  supposed  to  be  legally  married  to 
the  woman.  He  was  stricken  with  right-sided  pai-ah-sis  and  pai'tial 
aphasia ;  but  I  found  him  capable  of  answering  questions  and  of  read- 
ing a  httle  consecutively.  I  saw  him  twice  before  his  death,  and  be- 
tween my  two  "sasits  he  was  married  to  the  woman  with  whom  he  had 
been  living.  The  granting  letters  of  administration  to  his  wife  was  re- 
sisted by  some  of  his  relatives,  who  claimed  that  undue  influence  had 
been  used,  and  also  that  he  was  not  in  a  state  of  mind  to  know  what  he 
was  doing  when  he  was  married.  After  hearing  the  testimony  the  reg- 
ister gave  letters  of  administration  to  the  wife  and  the  case  was  dropped. 

The  question  of  interdiction  may  come  up  for  decision  when  an 

*  Kussmaul,  Zicmssen's  Cyclop(cclia  of  Practical  Medicine  (American  edition),  vol. 
xiv.,  p.  773. 

t  Bancroft,  Boston  Medical  and  Surgical  Journal,  vol.  civ.,  No.  21,  Mav  26,  ISSl, 
p.  483. 


266  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

aphasic  is  alleged  to  be  insane ;  and  the  decision,  as  in  tlie  case  of  the 
insane  not  aphasic,  may  resnlt  in  the  patient  going  to  an  insane  hos23ital, 
or  simply  being  put  nnder  the  control  of  a  committee  or  of  a  gnardian. 
Another  question  may  be  of  the  alleged  mahugering  of  deafness  or  of 
deaf -mutism  by  a  criminal,  a  soldier,  or  an  employee  wishing  to  shirk 
duty ;  and  still  another  whether  an  apparent  aphasia  is  one  of  the  phases 
of  alleged  hysteria.  Occasionally  aphasia,  the  resnlt  of  traumatism,  may 
have  a  decided  medico-legal  importance,  as  in  litigation,  because  of 
injiu'ies  resulting  in  aphasias ;  or  when  the  ability  of  an  aphasic,  who 
has  been  injured  with  criminal  intent,  to  recognize  an  alleged  assailant 
is  questioned.  In  varioiis  well-known  forms  of  insanity,  as  paretic 
dementia,  monomania,  katatonia,  confusional  insanity,  mania,  or  melan- 
cholia, the  peculiarities  of  the  speech  disorders  belonging  to  the  affections 
may  assist  in  the  early  or  late  diagnosis  of  such  cases,  and  may  thus 
have  a  bearing  upon  such  legal  matters  as  necessity  of  restraint,  relief 
from  responsibility,  or  discharge  after  recovery. 

It  is  not  possible  to  establish  rules  by  which  the  capacity,  compe- 
tency, or  resj)onsibility  of  aphasics  can  be  measui-ed.  This,  in  given 
cases,  is  largely  a  matter  for  judicial  decision  and  technical  interpreta- 
tion of  the  law.  In  aU.  civilized  countries,  and  in  different  States  of  a 
countrj^  like  oiu'  own,  the  administration  of  the  law  with  reference  to 
such  matters  as  wills,  deeds  of  trust,  civil  contracts,  restraint  in  asylums, 
and  particular  crimes,  whether  relating  to  aphasics  or  others,  is  based 
upon  precedents,  and  upon  legislative  and  other  enactments.  These 
may  sometimes  be  at  variance  with  what  is  just  and  equitable  from  a 
medical  point  of  view.  The  object  of  a  paper  like  the  present  is  chiefly 
to  show  the  methods  of  gauging  the  mental  status  of  those  affected  mth 
disorders  of  speech,  which  mental  status,  from  the  medical  point  of  view, 
would  be  the  criterion  of  competency  and  responsibility ;  but  such  studies 
might  lead  to  a  conclusion  that  a  testator  in  a  certain  case  was  competent 
to  make  a  valid  will,  although  his  testament  might  not  be  sustained  by 
a  court  because  of  a  technical  violation  of  a  provision  of  the  law. 

The  French  law  recognizes  tlu'ee  kinds  of  wills :  that  by  public  act 
before  notaries  and  witnesses  ;  the  holographic  will,  or  that  wi-itten  by  the 
testator's  own  hand  unguided  by  another ;  and  the  secret  will  {testament 
mystique).  The  secret  Avill  may  be  written  entirely  by  the  hand  of  the 
testator,  like  the  holographic  wiU,  or  be  wi'itten  b}^  another  person  and 
only  signed  by  him.  It  is  then  given  in  charge  of  a  notary  in  presence 
of  a  stated  number  of  witnesses,  who  countersign  the  envelope,  and  by 
whom  it  is  closed  and  sealed ;  and  upon  this  the  testator  T^^ites,  or  causes 
to  be  'wiitten,  that  this  is  his  ^^n\l  duly  signed  by  him.  Thus,  if  the  writ- 
ing and  signing  of  the  will  are  illegible  or  difficult  to  read,  this  act  acquires 
the  value  even  of  a  holographic  wiU.     (Gallard.) 

Under  even  these  or  similar  laws,  an  apliasic  who,  medically  speak- 
ing, might  be  entirely  competent  to  do  certain  acts,  as  could  be  deter- 
mined by  careful  medical  examination,  would  not  be  able  to  carry  out 
his  own  recognizable  wishes.  Even  expressive  and  correct  pantomime 
would  not  suffice  in  such  a  case.  Cases  of  this  kind  are  mentioned  by 
Legrand  du  Saulle  and  others. 


APHASIA  AND   OTREIi  AFFECTIONS  OF  SPEECH.  267 


DEFINITIONS  AND  TERiKNOLOGY — ^VARIETIES  OP   APHASIA. 

It  will  be  necessary  to  define  certain  terms  and  to  give  a  few  of  the 
most  important  facts  with  reference  to  the  natm'e  and  mechanism  of 
speech  and  its  disorders,  and  also  regarding-  the  sites  of  lesions  prodnc- 
ing  aphasias.  While  it  is  impossible  to  make  explicit  statements  with 
reference  to  the  mental  status — or  legal  statns,  which  is  sometimes  a 
very  different  matter — of  ai)hasics,  basing  sncli  statements  npon  the  loc;i- 
tion  of  a  lesion  in  a  certain  center,  zone,  or  commissure,  something  can 
be  done  in  this  direction,  and  at  least  one  object  is  to  show  how  far 
capacity  and  competency  may  be  inflnenced  by  the  site  of  a  lesion  which 
causes  an  aphasia. 

Before  the  term  apliasia,  which  means  "loss  of  speech,"  was  fully 
grafted  upon  medical  nomenclature,  and  to  some  extent  since,  numerous 
other  terms  have  been  used  to  describe  disorders  of  speech  from  cerebral 
disease.  Alalia  was  employed  by  Lordat  in  the  same  general  sense  after- 
ward accorded  to  aphasia,  but  it  is  not  now  used  or  it  is  restricted  to  the 
meaning  given  it  by  Kussmaul,  that  is,  an  entire  inabihty  to  utter  artic- 
ulate sounds,  ranking  it  under  the  heads  of  losses  and  defects  of  enun- 
ciation. Aphemia  has  also  been  used  by  Broca  and  others  for  cerebral 
speech  disturbances  in  general.  Ross  used  it  to  describe  the  commonest 
forms  of  motor  aphasia,  the  loss  of  the  power  of  communicating  thought 
by  articulate  words  ;  but  Bastian  has  suggested  that  aphemia  lie  confined 
in  its  definition  to  defects  of  speech  from  lesions  of  those  fillers  which 
connect  the  motor,  or,  as  he  would  saj^,  "kinesthetic"  centers  of  the  cere- 
brum with  the  nuclei  of  the  bulb.  McLane  Hamilton  has  suggested 
asemasia,  which  means  an  inability  to  communicate  by  signs  or  lan- 
guage ;  but  it  is  too  late  to  displace  the  word  "  aphasia,"  which  will  be 
used  in  this  paper  in  its  commonly  accepted  and  general  sense  to  indi- 
cate cerebral  loss  or  defect  in  both  language  and  signs. 

Formerly  the  terms  ataxic  apliasia  and  amnesic  aphasia  were  em- 
ployed almost  universally,  and  these  expressions  are  retained  by  high 
authorities.  Ataxic  aphasia  has  been  used  to  describe  the  aphasia  of  com- 
mon ty]ie  resulting  from  lesions  of  Broca's  convolution  and  the  immedi- 
ately adjacent  region,  on  the  supposition  that  the  affection  of  sjieech  is  an 
inability  or  incapacity  for  the  motor  coordination  of  words ;  but  as  it  is  a 
matter  of  dispute  whether  or  not  the  affection  should  be  regarded  as  par- 
alytic, or  even  sensory,  rather  than  ataxic,  it  is  best  not  to  continue  the 
use  of  this  expression.  Amnesia  is  loss  of  memory,  and  amnesic  aphasia 
is  the  term  wliich  has  been  apjiHed  to  those  affections  of  speech  which 
are  the  result  of  lesions  on  the  sensory  or  receptive  side  of  the  brain. 
Kussmaul  defines  amnesic  aphasia  as  the  incapacity  for  the  recollection 
of  words  as  acoustic  aggregates  of  sound ;  but  objections,  based  upon 
theoretical  considerations,  have  also  been  urged  to  this  term. 

Disregarding  for  the  present  differences  of  opinion  of  almost  equally 
high  authorities,  the  best  practical  subdivision  of  the  aphasias  is  into 
sensory  or  receptive,  and  motor  or  emissive.  Following  such  authoritii^s 
as  Kussmaul,  Charcot,  Broadbent,  and  Ross,  under  tlie  general  term 
sensory  aphasia  I  include  those  affections  of  speech  which  are  dependent 
upon  disease  located  in  the  receiving  jiart  of  the  brain.  Sensory  aphasia 
has,  therefore,  necessarily  several  varieties,  as  word-deafness  and  word- 


268  A   SYSTEM  OF   LEGAL    MEDICIXE. 

hlmdness,  terms  wMch  define  themselves;  and  cq^raxia,  sometimes  called 
sonl-blinduess,  mind-blindness,  or  objeet-blindness,  wliieli  is  defined  hj 
Knssmanl  as  an  affection  in  which  the  memorj^  for  the  nses  of  things  is 
lost,  as  well  as  the  understanding  for  the  signs  for  which  the  tilings  are  ex- 
pressed. To  test  for  apraxia,  as  suggested  by  Starr,*  it  is  onl}^  necessary 
to  present  various  objects  to  a  person  in  various  ways  and  notice  whether 
he  gives  evidences  of  recognition ;  to  have  him  watched  by  Ms  friends, 
who  will  be  able  to  tell  whether  he  still  chooses  his  articles  of  food  at  the 
table  intelligently ;  whether  he  still  knows  how  to  put  on  his  clothes ;  to 
use  various  toilet  articles ;  to  sew,  knit,  or  embroider  if  the  patient  is  a 
lady ;  or  to  admii-e  pictures  or  flowers  or  perfumes,  as  before  the  illness 
began. 

Motor  aphasia  includes  the  common  form  of  disorder  of  speech  some- 
times known  as  Broca's  a]3hasia,  and  in  addition  agraphia,  or  loss  of  the 
power  of  writing,  when  this  is  due  to  disease  of  the  graphic  centers  of 
tracts  in  the  motor  cortex. 

Other  affections  may  result  from  the  breaking  through  of  the  com- 
missures or  lines  of  connection  between  the  various  centers.  These  give 
us  what  are  known  in  general  terms  &^  paraphasias  or  conduction  aphasias, 
which  may  be  of  as  many  tj^es  as  there  are  eommissiu'es.  Sensory  and 
motor  centers  and  commissures  may  all  be  affected  at  the  same  time,  and 
this  gives  the  total  aphasia  of  some  writers,  or  what  is  perhaps  better 
called  by  Ross  comMned  sensory  and  motor  aphasia,  or  by  others  mixed 
aphasia.  Other  terms  in  use  are  those  descriptive  of  the  peculiarities  of 
sym]3tomatology  exhibited  by  the  different  varieties  of  aphasia  to  which 
reference  has  been  made,  as  alexia,  dyslexia,  and  paralexia.  Some  of  the 
s^anptoms  thus  designated  may  be  produced  by  either  sensory,  motor,  or 
conduction  disease,  or  by  combinations  of  these.  Alexia  is  abolition  of 
the  power  of  reading,  as  agraphia  is  that  of  writing ;  dyslexia  refers  to 
difficulty  or  fatigue  in  reading;  parcdexia  to  misuse  by  transposition  or 
substitution  of  either  syllables  or  words. 

An  important  variety  of  aphasia  from  the  medico-legal  point  of  view 
is  that  known  as  verhal  amnesia  or  the  aphasia  of  recollection.  Those 
suffering  from  this  disorder  may  be  neither  word-deaf  nor  word-blind, 
nor  be  directly  disturbed  in  motor  speech,  although  the  affection  may 
be  and  often  is  combined  with  other  forms  of  aphasia.  Pure  verbal 
amnesia  is  inability  to  recall  the  name  of  an  object,  quality,  or  event,  al- 
though the  conception  or  idea  of  it  is  present  in  consciousness.  This 
loss  of  word  memory  may  be  abnost  or  absolutely  total,  or  it  may  be  so 
slight  as  to  be  little  more  than  a  species  of  absent-mindedness.  The 
proper  word  is  not  revived  in  the  memory,  although  the  person  or  thing 
is  absolutely  heard  or  seen,  and  is  recognized.  Nouns,  and  especiallj'' 
proj^er  or  general  names,  are  the  parts  of  speech  most  commonly  lost, 
because  they  are  the  last  and  the  least  organized  in  the  brain.  Many 
instances  of  this  disorder  have  been  reported  by  writers. 

Besides  word-deafness  and  word-blindness,  disorders  known  as  psy- 
chical deafness  and  psychical  hlindness  occur  from  cerebral  disease :  the 
word  distiu'bances  are  perhaps  best  regarded  as  degrees  or  varieties 
of  the  more  comprehensive  psychicnl  affections.  A  case  of  psychical 
deafness,  however,  may  in  addition  to  word-deafness,  or  perhaps  inde- 

*  Starr,  Neiv  Tori-  Medical  Becord,  October  27.  1888. 


APHASIA    A  XT)    OTIIIin   AFFIJCTIOXS   OF  SPEKCII.  2fi9 

pendently  of  it,  have  lost  general  auditory  memory  for  ohjeets  and  for 
sounds  of  definite  import.  In  psychical  blindness  the  A-isual  memoiy  of 
forms  and  colors,  and  of  things  in  general,  may  be  lost,  or  the  power  of 
recognizing  by  sight  the  special  properties  of  ol)jects  may  be  impaired 
or  destroyed  ;  although  even  such  patients  may  preserve  sight  of  a  lower 
kind,  that,  for  instance,  which  would  enable  them  to  avoid  obstacles 
l)laced  in  their  path,  as  the  psychically  deaf  may  also  by  lower  centers 
appreciate  vibration  or  noise. 

Apraxia,  already  defined  as  the  inability  to  recognize  the  use  or 
meaning  of  objects,  it  will  be  seen  might  l)e  the  result  either  of  psychic- 
al blindness  or  psychical  deafness,  or  of  both.  Apraxia  and  verbal 
amnesia  are  not  necessarily  present  in  the  same  case.  It  is  conceivable 
that  an  individual  might  be  able  to  name  an  object  the  use  of  which  he 
did  not  recognize ;  and  in  a  common  form  of  verbal  amnesia  the  patient 
is  conscious  of  the  uses  and  properties  of  things  the  names  of  which  it 
is  impossible  for  him  to  re\dve  in  memory. 

CEREBRAL  CENTERS  AND  TRACTS   CONCERNED   IN  THE  SIECHAJSHSM  OF 

SPEECH. 

Various  schemes  and  diagrams  of  the  centers  and  tracts  of  speech, 
and  of  their  possible  lesions,  have  been  suggested,  and  almost  any  one 
of  these  might  answer  for  the  separation  of  aphasias  in  a  study  of  them 
for  medico-legal  or  other  practical  purposes.  Lichtheim  *  indicates  at 
least  seven  localities  for  diagnostically  separable  lesions,  without  includ- 
ing the  visual  or  concept  centers,  or  some  of  the  h^i^othetieal  inner  com- 
missures ;  and  these  might  be  readily  increased  to  ten  or  more  locations. 

The  principal  brain  centers  or  areas  concerned  with  the  phenomena 
and  mechanism  of  speech  are :  (1)  audit oiy  (center  of  auditory  images) : 
(2)  visual  (center  of  ^^sual  images) ;  (3)  concept ;  (4)  propositionizing 
(center  of  motor  images) ;  (5)  utterance;  (6)  gi'aphic  or  writing;  (7)  in- 
hibitory (higher  prefrontal  centers). 

Of  receptive  centers  I  have  mentioned  only  the  auditory  and  visual 
for  the  sake  of  simplicity,  although,  of  course,  impressions  received  by 
the  cerebral  centers  for  touch,  taste,  and  smell,  and  particularly  by  those 
for  touch,  may  sometimes  enter  into  the  mechanism  of  speech. 

The  chief  cerebral  tracts  and  commissures  concerned  "with  speech 
are :  (1)  the  entering  auditory  tract,  which  conveys  impressions  to  the 
autlitory  center ;  (2)  the  entering  visual  tract ;  (3)  the  commissiu-es  be- 
tween the  auditory  and  concept  centers;  (4)  the  commissures  between 
the  visual  and  concept  centers ;  (5)  the  commissures  between  the  auditory 
and  "sisual  centers ;  (6)  the  commissm^es  between  the  concept  and  pn)p- 
ositionizing  motor  center:  (7)  the  direct  tract,  sometimes  used,  between 
the  auditory  and  propositionizing  centers,  instead  of  the  innervation 
passing  by  way  of  the  concept  centers ;  (8)  the  short  commissure  between 
the  propositionizing  and  utterance  centers;  (9)  the  similarly  short  com- 
missure between  the  propositionizing  and  gi-aphic  or  wi-iting  centers : 
(10)  the  dii'cct  tract,  sometimes  used,  from  the  -visual  sensory  center  to 
the  motor  graphic  or  WTitiug  center;  (11)  the  tract  or  tracts  connecting 
the  motor  cortical  centers  concerned  with  speech  and  wiiting  ^vith  the 
<3enters  in  the  bulb  and  spinal  cord. 

*  Licbtheim.  lirahi,  vol.  vii.,  Janiiarv,  1885. 


270  A   SYSTEM  OF  LEGAL  MEDICINE. 


PARTICULAR  FORMS   OF   SPEECH  DISORDER  PRODUCED  BY  LOCALIZED 

LESIONS. 

Eestricting  ourselves  to  this  number  and  arrangement  of  cerebral 
speech  centers  and  pathways,  the  first  cerebral  tract  involved  in  spoken 
and  written  language  would  be  the  entering  auditory  tract — the  path 
between  the  primary  auditory  centers  in  the  bulb  and  the  cortical  center 
for  words,  which  is  situated  in  the  posterior  thirds  of  the  first  and  second 
temporal  convolutions.  Lichtheim  has  placed  this  path  in  the  left  tem- 
poral lobe,  and  believes  that  the  radiations  from  both  acoustic  nerves 
and  nuclei  come  together  in  this  side  of  the  brain.  Word-deafness  would 
be  the  chief  characteristic  of  a  lesion  of  this  entering  pathway,  as  it 
would  be  also  of  a  lesion  of  the  auditory  center  itself,  but  in  the  latter 
case  paraphasia  and  paralexia  would  be  also  present,  as  the  patient  would 
be  unable  to  verify  the  correctness  of  his  spoken  words  by  hearing. 

The  entering  tract  for  vision  passes  by  way  of  the  optic  radiations  of 
Gratiolet,  which  are  chiefly  in  the  occipital  lobe,  from  the  primary  optic 
centers  in  the  quadrigeminal  body  and  thalamus  to  the  cortical  centers 
for  words  in  the  angulo-occipital  region.  Word-blindness  would  be 
caused  either  by  lesion  of  this  entering  tract  or  of  the  visual  center  for 
words.  Experience  shows  that  other  symptoms,  such  as  mind-blindness 
and  hemianopsia,  are  often  associated  with  word-blindness,  because  the 
tracts  and  centers  concerned  with  the  functions  of  sight  impaired  in 
the  latter  disorders  are  closely  associated  with  those  which  take  part  in 
word  vision.  It  is  clear  that  one  form  of  alexia  or  abolition  of  the 
power  of  reading,  and  also,  of  course,  one  form  of  impairment  or  aboli- 
tion of  the  ability  to  write,  would  be  present  in  cases  of  word-blindiiess 
produced  by  lesions  thus  situated ;  but  it  must  be  remembered  that  the 
word-bhnd  can  sometimes  write  from  dictation  or  spontaneously,  largely 
by  the  aid  of  tactile  or  muscular  sense,  and  that  they  can  also  sometimes 
copy  printed  or  written  text  which  they  may  not  be  able  to  read  or  un- 
derstand, probably  as  they  would  copy  a  geometrical  or  other  figure. 

Recent  authorities  are  generally  agreed  as  to  the  necessity  of  some 
area  and  mechanism  on  the  sensory  or  receptive  side  of  the  brain,  or  in- 
termediate between  it  and  the  motor  cerebrum,  for  a  higher  intellectual 
process  than  the  mere  registration  of  auditory  and  visual  impressions — 
for  the  formation  of  concepts  in  contradistinction  to  percepts  which  are 
represented  in  the  true  cerebral  centers  of  hearing  and  sight,  for  the  or- 
ganization in  consciousness  of  definite  ideas  and  the  identifying  of  these 
with  names.  As  to  the  existence  of  topographically  separated  centers  or 
regions  for  this  higher  process,  considerable  difference  exists.  Some  ad- 
vocate a  special  naming,  idea,  or  concept  center.  Others  do  not  consider 
that  a  center  for  the  elaboration  of  concepts  is  localized  in  any  particular 
spot  or  area  of  the  brain,  but  that  this  process  is  rather  the  result  of  the 
combined  action  of  the  whole  sensorial  sphere,  and  that  the  commissures 
between  the  sensory  and  motor  speech  centers  and  this  conceptual  sphere 
consist  of  converging  radiations  from  various  parts  of  the  cortex  to  the 
receptive  and  emissive  centers.  Ross,  for  instance,  holds  that  on  passing 
from  thinking  by  percepts  to  thinking  by  concepts,  and  from  that  to 
thinking  by  abstracts,  there  are  no  new  centers  introduced,  but  only 


ArUASIA    AND    OTIIKI!   AFFECTIONS   OF  SPEEfJI.  271 

coiiiplieation  upon  eoiiiplicalion  of  one  perceptive  center.  Broadbent,* 
on  the  other  hand,  believes  tliat  a  certain  convohitional  area,  whi('li  might 
be  called  the  "idea  center"  or  "naming-  center/'  exists  on  the  sensory  or 
upward  side  of  the  nervous  system,  and  conjectures  that  it  is  situeted  on 
the  under-surface  of  the  temporosplienoidal  lobe  near  its  junction  with 
the  occipital  lobe,  as  it  seems  to  him  that  fibei's  from  all  the  convcjlutions 
in  which  perceptive  centers  have  been  placed  converge  to  and  end  in  the 
gray  cortex  of  this  region. 

Rosenthal,  who  is  cited  by  Ross,  has  recorded  a  case  of  verbal  am- 
nesia without  word-deafness  in  a  patient  suffering  from  general  paralysis, 
which  defect  of  speech  was  ushered  in  by  an  apoplectiform  attack,  and 
persisted  unchanged  for  upward  of  two  years.  At  the  autopsy,  besides 
evidence  of  a  chronic  leptomeningitis,  an  old  focus  of  softening  was  found 
in  the  second  and  third  temporosplienoidal  convolutions,  the  tii'st  tem- 
porosplienoidal convolution  being  quite  free  from  disease. 

After  all,  the  existence  of  a  special  development  or  organization  of 
the  cortex  foi'  thinking  by  concepts  and  for  the  clo tiling  of  ideas  in 
names  is  recognized  by  authorities  like  Ross,  Bastian,  and  others,  who 
differ  from  Broadbent,  Charcot,  and  Kussmaul,  and  the  school  of  believers 
in  separate  concept  centers,  only  in  not  restricting  this  organization  to 
an  area  absolutely  set  apart.  It  is  neither  improbable  nor  unpliilosoph- 
ical  that  a  region  conveniently  intermediate  between  all  recepitive  and 
emissi'^'e  centers  concerned  in  the  mechanism  of  S]3eech  may  constitute  a 
special,  but  not  narrowly  limited,  area  of  the  cortex,  which  is  the  ana- 
tomical substratum  for  concepts  and  the  names  which  they  awaken. 
The  chief  affections  of  speech  and  of  thought  due  to  lesion  of  this  nam- 
ing or  concept  cortex,  whether  it  is  regarded  as  an  isolated  area  or  as  a 
complication  of  centers  and  paths  spread  over  the  whole  sensorial  sphere, 
are  varieties  of  verbal  amnesia  or  the  aphasia  of  recollection,  with  usu- 
ally additional  symptoms,  such  as  loss  of  understanding  of  spoken  or 
written  language,  or  of  volitional  speech  or  writing,  because  of  the  al- 
most necessary  involvement  of  commissures  to  other  sensory  and  motor 
centers. 

Various  affections  of  hearing  and  speech,  or  of  vision  and  speech, 
may  be  due  to  lesions  of  the  inner  commissures  between  the  auditory 
and  visual  centers,  or  between  these  and  the  concept  centers,  and  like- 
wise various  degrees  of  disturbance  of  thought  and  speech  from  lesions 
of  the  paths  between  these  concept  centers  and  the  motor  regions  for 
speech  ;  and  these  disorders  will  partake  of  the  receptive  or  sensor  char- 
acter on  the  one  hand,  or  of  the  emissive  or  motor  character  on  the  other, 
according  as  the  lesion  is  respecti^^ely  toward  the  sensory  or  the  motor 
side  of  the  brain.  Isolated  word-blindness,  according  to  Lichtheim  and 
other  observers,  is  the  result  of  a  break  between  the  visual  and  auditoiy 
centers  of  word  representation.  Paraphasia  and  ^paragraphia,  or  distui-b- 
ances  in  speaking  and  writing  shown  in  the  misuse  and  jumbhug  of 
sounds  and  Avords,  result  from  interruption  in  the  commissure  between 
the  auditory  and  motor  speech  centers,  or  in  the  are  which  unites  visual, 
auditory,  and  motor  centers. 

If  we  acknowledge  the  existence  of  concept  areas  as  practicallj''  dis- 
tinct centers  or  regions,  or  even  if  we  take  the  view  that  they  exist  as 

*  Broadbeut,  Brain,  vol.  i.,  January,  1SS7. 


272  ^   SYSTEM  OF  LEGAL  MEDICLNE. 

complications  or  elaborations  of  the  trne  auditory  and  visual  and  other 
receptive  centers,  then  lesions  of  these  higher  cell  clusters,  particularly 
if  extensive,  might  of  course  give  rise  to  conceptual  disorders  of  speech 
and  thought.  Severance  of  association  tracts  between  the  concei3t  and 
the  perceptive  centers  -may,  however,  often  be  the  cause  of  different 
varieties  of  these  psychical  disorders,  according  to  the  tracts  dissevered. 
To  give  a  simple  illustration,  one  of  my  patients,  who  was  both  object- 
bhnd  and  word-blind,  could  not  recognize  a  piu-se  by  sight,  but  on  hand- 
ling it,  examining  its  clasp,  etc.,  she  at  once  named  it  correctly ;  probably 
the  tracts  between  the  visual  perceptive  and  higher  visual  areas  were  de- 
stroyed, as  well  as  the  word  centers,  while  the  tactual  centers  and  lines 
of  communication  from  them  to  the  concept  region  Avere  unaffected. 

Dyslexia  is  probably  most  frequently  due  to  a  partial  break  or  lesion 
in  the  commissm*es  between  the  visual  and  the  motor  aphasic  centers, 
although  imperfect  destruction  of  the  commissm^e  between  the  casual  and 
auditory  centers,  or  between  those  for  word  hearing  and  Broca's  convo- 
lution, might  cause  some  degi-ee  of  this  disorder.  Paralexia,  like  jDara- 
phasia,  may  be  due  to  severance  of  the  communications  between  either 
the  auditory  or  visual  centers  and  the  motor  speech  regions. 

The  pm-est  forms  of  motor  speech  defect  will,  of  course,  be  due  to  an 
isolated  lesion  either  of  Broca's  convolution,  which  is  the  propositioniz- 
ing  center  of  Broadbent,  or  of  the  utterance  centers  at  the  foot  of  the 
central  convolutions,  or  of  both  together.  Such  cases,  although  not  very 
numerous,  have  been  rej)orted ;  some  which  are  well  known  in  the  litera- 
ture of  aphasia  seem  to  clearly  prove  that  the  loss  of  propositionizing 
power  is  present  only  when  the  lesion  is  absolutely  limited  to  Broca's 
convolution. 

While  it  is  true  that  the  power  of  building  and  rehearsing  in  the 
mind  a  phrase  or  sentence  and  the  power  of  uttering  it  are  commonly  lost 
together,  still  such  a  combination  does  not  always  exist  in  aphasic  cases. 
Doubtless  two  processes  of  this  kind,  which  are  so  intimately  connected 
and  so  often  jointl}'  lost,  have  their  anatomical  substrata  in  closely  ad- 
joining locahties,  and  one  so-called  center  might  be  considered,  after  the 
manner  of  Ross,  simply  as  a  comph cation  or  extension  of  the  other;  but 
still  the  more  elaborated  area  is  separated,  even  if  it  be  only  the  shortest 
distance,  from  the  other. 

Aj^hasia  from  the  destruction  of  Broca's  convolution  should  give  loss 
of  volitional  speech  and  volitional  writing,  and  if  the  utterance  center  or 
utterance  portion  of  the  compound  center  is  destroyed  also,  the  power  of 
repeating  and  of  reading  aloud  should  also  be  lost.  Spoken  and  written 
words,  however,  could  be  understood,  and  the  faculty  of  copjing  retained. 

The  destruction  of  the  short  commissures  l^etween  propositionizing 
and  gi'aphic  centers  must  nearly  always  take  i3lace  in  lesion  of  Broca's  con- 
volution and  its  subcortex,  and  hence  give  motor  aphasia  and  agraphia. 
In  a  case  recorded  by  the  ^Aaiter  of  orolingual  monoplegia  in  which  a  focus 
of  strictly  yellowish  softening  was  found  involving  the  lower  extremities 
of  the  central  convolutions  both  on  their  external  and  Sylvian  surfaces, 
and  a  spot  one-half  inch  in  diameter  about  the  middle  of  the  internal 
portion  of  the  island  of  Reil,  utterance  was  largely  abolished,  while  prop- 
ositionizing power  remained  intact. 

Clearly,  in  most  cases  of  destruction  of  the  motor  speech  centers,  as 
the  subcortex  usually  to  some  extent  takes  part  in  such  lesions,  commis- 


APHASIA   AND    OTHER  AFFECTIONS   OF  SPEECH.  273 

«iires  of  some  kind  must  be  involved,  and  lionee  varieties  of  eonnnissnral 
or  etniduction  apliasia  are  nearly  always  l)lended  with  motor  disorders, 
but  tliese  are  oftiMi  recovered  from  in  part  or  whole. 

Agraphia,  or  the  loss  of  power  of  writing',  which  may,  of  course,  be  of 
the  liighest  importance  in  medico-legal  directions,  may  l)e  due  to  lesions 
variously  sitiuited.  I  have  alread}'  spoken  of  what  might  be  termed  the 
sensory  forms  of  agraphia  due  to  lesions  of  the  visual  centers  or  of  the 
entering  visual  tracts,  but  even  motor  agraphia  is  of  several  kinds.  The 
patient,  for  example,  may  be  unable  to  write  spontaneously,  although  he 
can  from  dictation,  and  he  may  at  the  same  time  be  able  to  coi)y  either 
written  or  printed  text ;  or,  again,  he  may  not  have  the  al)ility  to  wiite 
either  from  dictation  or  by  copying.  Lesions  situated  in  several  places 
may  give  rise  to  motor  agraphia ;  for  instance,  in  the  fii-st  place,  in  the 
special  motor  centers  concerned  with  writing.  Agraphia  may  again  be 
dependent  upon  lesions  of  the  tract  uniting  the  concept  "udth  the  speech 
and  wi'iting  centers,  and  if  a  direct  separate  tract  exists  between  the 
visual  and  the  graphic  centers,  the  power  of  cop^dng  ma}'  in  such  case 
be  retained.  As  propositionizing  is  as  necessary  to  volitional  writing  as 
to  volitional  speech,  destriiction  of  the  third  left  frontal  mil  cause  more 
or  less  agraphia  as  well  as  aphasia.  "■  The  same  result,''  says  Gowers, 
"  follows  an  isolating  lesion  just  beneath  the  cortical  center,  and  hence 
the  path  to  the  arm  center  must  be  by  the  '  associating  fibers '  of  the  sub- 
jacent white  substance,  and  not  the  gray  matter  of  the  cortex.  Bnt  it  is 
conceivable  that  a  subcortical  lesion  may  be  so  placed  as  to  interrupt  the 
paths  to  the  internal  capsule  and  to  the  opposite  hemisphere,  and  not  that 
to  the  arm  center.  In  such  a  case  there  would  be  permanent  loss  of 
uttered  speech  without  loss  of  power  of  Avriting.  Such  a  condition  has 
.actualty  been  observed." 


THE  MENTAL'  STATUS   OF   SEXSORT  APHASICS. 

In  general  terms  it  is  doubtless  true  that  mental  capacity  and  its 
manifestations  are  impaii^ed  most  iu  those  forms  of  amnesia  or  aphasia 
which  are  the  result  of  lesions  on  the  sensory  side  of  the  brain,  that  is, 
in  word-deafness,  word-bhndness,  iu  the  various  forms  of  apraxia  or 
mind-blindness,  and  in  those  combined  forms  of  speech  and  pantomimic 
distnrbance  ^^-llich  are  due  to  lesions  of  the  receptive  or  impressive 
mechanism  of  speech.  Words  seen  or  heard  fail  to  rcAdve  the  ordinarily 
appropriate  ideas  in  memory.  Mind-blindness  is  uot  alwaj's  associated 
with  word-blindness,  nor  psychical  deafness  with  word-deafness,  but 
when  such  an  association  is  present  it  would  requu*e  the  closest  scrutiny 
of  the  particulars  of  a  case  of  alleged  capacity  or  incapacity  to  determine 
the  true  status  of  the  individual,  and  the  presumption  would  be  rather 
against  than  in  favor  of  the  preservation  of  mental  power  for  definite 
purposes.  More  commonly  than  otherwise,  word-blindness  and  word- 
deafness  are  present  in  the  same  case,  and  quite  often  the  more  serious 
psychical  disorders  are  also  associated.  While,  however,  all  this  is  true, 
it  is  not  correct  that  word-deafness  or  word-blindness,  or  even  mind- 
l)lindness  or  psychical  deafness,  necessarily  destroys  mental  integrity  to 
such  an  extent  as  to  shut  out  testamentary  capacity,  the  ability  to  make  con- 
tracts, to  testify  as  a  witness,  or  to  take  care  of  one's  person  or  property. 


274  -4   SYSTEM  OF  LEGAL  MEDICINE. 


I\IENTAL  STATUS  IN  WORD-DEAFNESS. 

Wliat  is  the  mental  status  of  a  case  of  word-deafness  ?  With  what, 
voluntary  acts  would  such  an  affection  interfere  ?  First  in  importance 
comes  the  question  of  testamentary  capacit}^  and  similar  exercises  of  men- 
tal power  in  assenting  or  dissenting  to  legal  papers.  Gowers  says  that 
word-deafness  is  incompatible  with  will-making,  because  it  is  impossible  to 
know  whether  the  testator  really  understands  what  is  said  to  him ;  but  this 
is  putting  the  matter  too  strongly.  If  he  is  only  word-deaf  from  lesion  of 
either  the  entering  auditory  tracts  or  of  the  auditory  center,  but  still  pre- 
serves tuR  cerebral  visual  power,  and  intact  lines  of  communication  be- 
tween the  visual  center  and  the  motor  areas  for  speech  and  writing,  a  will 
might  be  made,  or  other  legal  papers  might  express  his  real  intentions.  It 
ought  not  to  be  necessary,  in  other  words,  for  competency  that  the  per- 
son should  be  responsive  by  every  channel  of  communication.  This,  as 
in  so  many  other  cases  of  the  kind  we  are  discussing,  should  be  studied 
on  its  own  merits,  and  testimony  as  to  how  the  disputed  act  was  done 
should  be  clear  and  unmistakable.  Evidently  a  completely  word-deaf 
]3atient  could  not  express  either  assent  or  dissent  by  hearing,  and  pecul- 
iar statutes  might  have  some  bearing  on  the  capacity  of  a  case  of  word- 
deafness  ;  for  instance,  if  it  were  required  by  statute  that  the  testator 
should  be  addressed  by  sj)oken  words.  If  he  was  capable  of  assenting 
or  dissenting  with  certainty  by  any  of  the  legitimate  or  legal  means  of 
communication,  he  might  be  competent.  Some  word-deaf  patients  are 
or  become  able  to  communicate  in  spoken  or  written  language,  but  if 
the  lesion  is  complete  the  interference  with  all  methods  of  communication 
will  also  be  nearly  complete  until  new  centers  are  educated  and  new  lines 
of  communication  opened,  or  compensation  takes  place  through  the  other 
hemisphere.  Complete  word-deafness  is  therefore  a  serious  affection  in 
its  direct  effects  on  thought  and  its  expression,  and  also  because  of  the^ 
conditions  with  which  it  is  likely  to  be  complicated.  Bastian  says  that 
a  totally  word-deaf  patient  might  perhaps  not  understand  wiitten  lan- 
guage, but  acknowledges  that  this  ability  might  persist  to  some  extent 
through  the  action  of  the  opposite  hemisphere.  In  spite  of  the  serious- 
ness of  word-deafness,  it  is  a  mistake  to  conclude  too  hastily  that  the  in- 
dividual is  either  incompetent  or  in  an}^  technical  sense  insane. 

Word-deafness  is  one  of  the  forms  of  hearing  and  speech  disturbance 
from  which  partial  recoveries  are  often  made  and  total  recoveries  some- 
times occm*.  In  a  number  of  the  cases  of  combined  sensory  and  motor 
aphasia  observed  at  the  Philadelphia  Hospital,  word-deafness,  at  an  early 
jDcriod  almost  complete,  rapidly  or  gradually  disappeared,  but  not  always 
fully.  Many  of  the  patients  responded  to  the  last  with  difficulty  or 
slowness  to  spoken  words.  In  the  consideration  of  the  medico-legal  as- 
pects of  word-deafness  the  fact  that  patients  improve  or  recover  should 
be  constantly  borne  in  mind.  The  most  conflicting  testimony  might  be 
trutlif  ull}'-  given  about  the  condition  and  the  competency  and  responsi- 
bility of  an  individual,  if  such  testimony  were  based  upon  observations 
made  over  a  period  of  a  few  years  or  even  months. 

The  case  of  the  French  Professor  Lordat,  which  has  become  classic 
in  works  on  aphasia,  is  interesting  in  this  as  in  other  particulars.  After 
a  fever  he  suddenly  lost  his  jjowers  of  speech,  and  was  word-deaf — words 


AVIIASIA    AND    OTUEU   AFFECTIONS   OF  SPEECII.  275 

■fell  unrecog'iiizod  upon  liis  ear ;  but  after  many  weeks  he  reeovei-ed,  i-c- 
sumed  liiw  professional  work,  and  wrote  a  valual)le  analysis  of  his  own 
case.  Sehniidt's  ease,  (pioted  by  Kussniaul,  is  interesting-  as  sh(j\ving 
the  charaeteristie  synij)tonis  in  a  word-deaf  ease,  and  also  illustrates  the 
fact  tliat  word-deafness  and  hig'li  grades  of  verbal  annn'sia  may  in  large 
part  disappear.  Recovery  took  place  slowly.  She  did  not  understand 
short  sentences  until  after  a  lapse  of  half  a  year,  and  then  oidy  when 
they  were  pi'onounced  slowly  and  distinctly.  Even  to  the  last  there  re- 
mained some  difficulty  in  speaking. 

A  word-deaf  patient  migiit  be  able  to  write  a  will  understandingly ; 
he  might  retain  or  soon  acquire  sufficient  powers  in  speaking  to  give  as- 
sent or  dissent,  or  even  to  express  an  opinion ;  he  might  retain  certain 
powers  of  pantomime,  visual  centers  and  connecting-  tracts  remaining 
undiseased  and  pervious,  and  the  motor  areas  for  pantomimic  speech  not 
being-  destroyed.  It  must  not  be  supposed  that  his  condition  would  be 
as  high  mentally  as  that  of  a  patient  deaf  and  dumb  from  peripheral 
disease,  as  scarlet  fever,  who  had  with  the  aid  of  vision  trained  himself 
in  the  use  and  comprehension  of  sign  language.  Although  secondary 
atrophj'  of  hearing  or  speech  centers  occm-s  in  cases  of  peripheral  deaf- 
ness, a  disturbance  of  mental  equilibrium  occui-s,  and  to  some  extent 
persists,  in  cases  of  cerebral  deafness  which  is  not  present  in  the  ordi- 
nary deaf  and  dinnb.  Cerebral  centers  and  lines  of  communication  are 
at  first  untouched  in  the  latter  cases,  and  the  visual  and  manual  training 
which  is  pursued  takes  possession  of  and  utilizes  everything  possible. 

Lichtheim  records  a  valuable  case  of  word-deafness  from  lesion  of  the 
cerebral  auditory  tract,  a  rare  form  of  recorded  lesion.  This  patient,  al- 
though word-deaf,  differed  in  striking  particulars  from  a  case  of  word- 
deafness  or  speech-deafness  from  lesion  of  the  center  for  auditory  images. 
While,  for  example,  he  could  not  understand  spoken  language,  had  lost 
the  faculty  of  repeating,  and  that  of  writing  from  dictation,  he  preserved 
intact  volitional  speech  and  writing,  the  understanding  of  writing,  the 
ability  to  copy  words,  and  finally  the  faculty  of  reading  aloud  properly, 
these  last  being  lost  in  cases  of  auditory-center  deafness.  He  had  neither 
paraphasia  nor  paragraphia,  because  the  arc  uniting  auditory,  concept, 
and  motor  centers  was  unbroken.  This  man's  available  mental  power 
was  greater  than  that  of  an  ordinary  ease  of  word-deafness.  He  was,  in 
fact,  a  teacher  and  a  journalist,  and  continued  with  success  the  business 
of  writing  articles  for  the  newspapers.  He  could  understand  noises  and 
other  sounds  of  definite  import,  but  not  speech.  He  spoke  with  absolute 
accuracy,  but  with  a  slight  drawl ;  he  could  find  substantives,  even  com- 
plex ones,  and  proper  names.  He  copied  an  I  O  U  wi-itten  by  Lichtheim, 
and  gave  it  to  his  wife,  remarking,  "  You  see,  you  have  money." 


MENTAL   STATUS   IN  WORD-BLINDNESS. 

A  variety  of  curious  problems  may  be  presented  by  patients  suffering 
from  pure  word-blindness,  or  from  this  and  some  of  its  usual  complica- 
tions, as  word-deafness,  psychical  blindness  or  deafness,  verbal  amnesia, 
or  paralexia.  I  have  already  stated,  for  instance,  that  the  word-blind 
can  sometimes  write  spontaneously  or  from  dictation,  or  even  copy 
writing  which  they  do  not  undei'stand.     Such  matters  as  the  simple 


276  -^   SYSTEM  OF  LEGAL  MEDICINE. 

signing  of  a  name  to  a  clieck,  to  a  will,  or  other  document,  are  often, 
points  in  dispute,  and  yet  the  ability  to  do  this  is  retained  in  many  eases 
where  the  patient  is  not  only  word-blind,  but  so  completely  so  as  to  be 
able  to  -wTite  nothing  but  his  autograph.  Letters  may  be  understood 
when  words  are  not.  The  understanding  for  figiu'cs  may  be  lost  or  re- 
tained. A  patient  reported  by  Broadbent — a  case  which,  after  a  time, 
fell  into  my  own  hands — could  not  at  first  tell  how  many  two  and  two 
made,  but  in  two  weeks  learned  to  add  together  two  low  figures,  and 
rapidly  thereafter  gained  in  his  understanding  of  figures.  Trousseau 
has  recorded  the  case  of  an  accountant  who  could  read  off  the  sum  766 
fig-ure  for  figure,  but  did  not  know  what  the  figm-e  7  meant  before  the 
two  6's.  Proust,  cited  by  Kussmaul,  records  another  aphasic  who,  al- 
though he  could  no  longer  count  in  words,  could  add  and  subtract  on 
paj)er,  and  even  multiply  pretty  well. 

That  an  individual  is  not  able  either  to  read  or  to  wi'ite  because  of 
word-bhndness  should  not  absolutely  invalidate  the  writing  or  signing 
of  a  will  or  other  document,  although  such  patient  is  not  exactly  in  the 
same  condition  as  one  who  has  never  been  educated  to  read  or  write, 
or  has  lost  sight  through  extra-cerebral  disease.  The  general  mental 
impairment,  the  possibility  of  the  existence  of  hallucinations  or  delusions, 
and  the  distiu'bance  of  the  equilibrium  of  thought  processes,  must  aU  be 
taken  into  consideration. 

Cases  of  interest  in  connection  with  the  discussion  of  word-blind- 
ness and  of  agraphia  are  mentioned  by  Legrand  du  SauUe  and  Bate- 
man.  An  aphasic,  fifty  years  old,  wished  to  make  a  will,  and  desired 
to  leave  an  old  domestic  a  remembrance  of  some  importance.  He- 
made  the  most  strenuous  efforts  to  get  together  words  and  express  on 
paper  his  will  in  the  matter,  but  the  words  would  not  form  an  intelligible 
sentence,  and  the  wiiting  was  incorrect  and  in  some  places  undecipher- 
able. This  defect  of  coordination  of  the  will  and  of  movement  could 
not  be  overcome,  and  he  died  before  he  could  make  the  will  he  so  muck 
desired,  to  the  grief  of  the  testatrix. 

Boucher  tells  of  a  hemiplegic  affected  with  word-amnesia,  who  Avished 
to  make  a  wiU  and  give  a  certain  sum  of  money  to  a  relative  who  had 
taken  great  care  of  him.  In  spite  of  the  most  expressive  gestures  and 
pantomime  he  had  great  difficulty  in  making  himself  understood.  He 
succeeded,  however,  and,  the  clew  found,  he  was  able  to  carry  out  his- 
washes. 

The  proof  of  testamentary  capacity  of  a  word-blind  patient,  or  the 
vahdity  of  a  written  instrmnent  alleged  to  have  been  prepared  by  or  for 
him  and  having  his  signature,  would  have  to  depend  largely  upon  col- 
lateral evidence.  If  it  could  be  shown  that  such  a  patient  had  written 
a  short  contract,  wiU,  or  other  document,  and  then  had  had  it  read  to 
him,  and  had  signified  his  assent  to  its  contents,  and  if  the  evidence  was 
in  favor  of  his  general  mental  stability,  his  testamentary  and  general 
mental  capacity  should  be  sustained.  If  it  should  be  attemjjted  to  prove 
that  such  a  patient  had  read  a  document  in  question,  and  thereby  as- 
sented to  it  before  signature,  the  evidence  Avould  be  against  its  validity 
and  his  capacity.  A  word-blind  patient  recognizing  his  defect,  but  not 
being  word-deaf,  and  in  possession  of  his  general  mental  faculties,  might 
have  a  will  or  other  legal  paper  written  for  him,  and  then  read  to  him, 
and  signify  his  assent  to  its  contents  by  gesture,  by  his  autograph,  or 


APHASIA    AM)    OTIIEU   AFFECTIoyS   OF  SrEELU.  ^217 

l)y  his  nuirk.  The  i)ossil)ility  of  deception  liaving  been  practiced  up(ju 
tlie  writer  or  testator  in  such  a  case  shonkl,  of  course,  be  taken  into  con- 
sideration and  ehniinated.  Word-blindness,  Hke  word-deafness,  often 
improves  so  as  to  chang-e  the  visual  receptive  jjowers,  and  possibly  the 
capacity  and  competency  of  the  patient. 

Tlie  following  (uisc^  will  serve  to  illustrate  some  of  the  points  likely 
to  arise  in  the  settlement  of  problems  associated  with  conditions  of  word- 
blindness  and  verbal  amnesia.  The  patient  was  a  married  woman  sixty- 
six  years  old,  who  had  had  an  attack  of  hemiparesis.  Examination 
showed  that  she  had  right  lateral  hemianopsia  without  Wernicke's  pupil- 
lary inaction.  Testing-  her  in  a  variety  of  ways  it  was  found  that  she 
could  recognize  objects  seen,  heard,  felt,  smelled,  or  tasted.  Until  a 
short  time  before  examination  she  had  been  al)le  to  recognize  persons 
on  the  street,  altliough  she  could  not  name  them ;  but  this  power  of  rec- 
ognition of  persons  was  leaving  her.  She  understood  what  was  said  to 
her.  She  had  four  sous,  and  evidently  could  tell  one  from  the  other^ 
but  could  not  correctly  name  them,  just  as  likely  as  not  calling  one  by 
another's  name.  She  understood  what  was  read  to  her,  but  could  not 
read,  as  she  did  not  understand  printed  or  written  words.  She  coidd 
sign  her  name  aud  write  a  few  short  "words  at  dictation,  although  the 
writing,  except  her  name,  was  so  imperfect  as  to  be  almost  illegible,  ex- 
cept in  the  case  of  a  small  word  like  "  cat."  She  could  recognize  an  ob- 
ject by  sight,  hearing,  or  touch ;  she  could  not  name  it  correctly  from 
seeing  it,  but  could  do  so  from  touch ;  or  after  it  was  told  to  her  she 
would  indicate  that  she  knew  the  name  but  could  not  recall  it.  She 
called  a  stamp  held  before  her  a  "  ticket "  or  a  "  letter,"  and  said  she 
knew  what  it  was  but  could  not  name  it.  She  called  pills  "  pencils,"  but 
knew  what  they  were  used  for  although  she  named  them  wrongly. 
When  a  paste-bottle  was  held  up  before  her  she  named  it  correctly,  but 
called  a  postal  card  a  ^'  stamp,"  although  she  knew  what  it  was.  She 
called  a  watch  a  "key,"  and  said  it  looked  like  a  key.  When  some  keys 
were  held  up  before  her  she  said  they  were  "locks,"  aud  e\4dently  knew 
their  uses.  On  liolding  a  pocket-book  before  her  she  could  not  name  it, 
but  did  this  quickly  when  she  took  it  in  her  hand. 


BIENTAL   STATUS   IN   VERBAL   AIMNESIA, 

The  medico-legal  bearings,  civil  and  criminal,  of  verbal  amnesia,  or 
the  aphasia  of  recollection,  open  an  interesting  tield,  and  one  not  alto- 
gether unexplored  b}^  writers  on  disorders  and  disturbances  of  speech. 
It  is  rarely  an  isolated  symptom.  It  is  frequently  associated  with  aprax- 
ia  in  some  of  its  forms,  or  with  word-blindness  or  word-deafness,  or 
both  ;  it  may,  indeed,  be  combined  in  the  same  case  with  abnost  all  other 
aphasic  affections.  Most  commonly,  as  would  be  expected,  it  is  combined 
Avith  sensorial  aphasias  and  apraxias.  I  have  already  discussed  the 
question  of  special  naming  or  concept  centers,  leaning  to  the  views  of 
those  who  hold  to  the  aggregation  of  these  concept  centers  into  a  more 
or  less  isolated  field  or  zone,  but  that  this  concept  field  is  probably 
not  limited  to  one  spot  in  the  sensorial  sphere.  When  more  perfect 
knowledge  of  localization  is  attained,  it  will  probably  be  found  that  the 
concept  region  of  the  brain  is  a  comparatively  large  but  connected  area^ 


278  ^   SYSTEM  OF  LEGAL  MEDICINE. 

interlacing  among  various  centers  for  percepts  in  sucli  a  way  as  to  make 
certain  portions  of  it  conveniently  intermediate  anatomically  between 
particular  percept  centers  and  the  special  motor  or  emissive  centers  with 
which  they  are  most  intimately  correlated.  Lesions  somewhat  variously 
distributed  and  extended  will,  therefore,  give  rise  to  forms  of  amnesia 
and  apraxia ;  and  strange  symptom-pictures,  difficult  to  analyze  and  to 
refer  to  these  lesions,  will  sometimes  be  presented  to  the  clinician  and 
medical  jurist. 

The  loss  of  the  faculty  of  recalling  words  must  interfere  to  some  ex- 
tent with  the  acts  of  thinking  as  well  as  with  expression.  Kussmaul 
holds,  and  doubtless  correctly,  that  amnesic  aphasia  in  its  most  severe 
forms  must  render  thought  mixed  and  confused,  and,  unless  the  affection 
be  merely  a  light  form  of  the  aphasia  of  recollection,  it  is  almost  always 
accompanied  by  a  pronounced  diminution  of  intelligence.  We  should 
not  be  satisfied  with  a  generality  like  this,  important  as  it  may  be,  but 
should,  in  studying  individual  cases,  separate  the  varieties  of  verbal 
amnesia  and  apraxia  into  classes,  based  upon  a  study  of  the  relations  of 
the  symptoms  presented  to  the  sites  and  extensions  of  the  lesions  on 
whicli  these  symptoms  are  dependent.  Those  deep  disturbances  of 
speech  and  thought  which  are  dependent  upon  large  lesions  destroying 
and  disrupting  various  percept  and  concept  centers,  and  the  lines  of 
communication  between  them,  must  so  weaken  and  confuse  the  mental 
powers  as  to  make  sanity  and  responsibility  in  criminal,  and  competency 
in  civil,  cases  often  a  matter  of  gravest  doubt. 

Many  illustrations  of  forms  of  verbal  amnesia  and  its  most  frequent 
associations  have  been  recorded  in  the  classical  treatises  on  aphasia,  and 
here  and  there  in  journals  and  text-books,  but  I  will  only  refer  to  two 
or  three.  Kussmaul  cites  Bergmann's  case,  in  which  nouns  had  disap- 
peared from  the  patient's  vocabulary,  but  he  still  had  command  of  the 
verbs.  A  pair  of  scissors  he  called  that  with  which  one  cuts;  the  win- 
dow, that  through  which  one  sees,  through  which  the  room  is  illumined, 
etc.  The  same  author  also  gives  the  well-known  case  reported  by  Hun 
of  Albany  of  a  farrier  who  understood  what  was  said  to  him,  but  al- 
though his  tongue  was  freely  movable  he  could  not  find  words  and  had 
to  make  himself  understood  by  signs.  If  the  word  was  written  out  for 
him  he  was  able  to  spell  it,  and  could  pronounce  it  after  a  few  attempts. 
When  he  was  able  to  pronounce  a  word  he  was  also  able  to  write  it. 
Bateman*  records  the  case  of  a  merchant  who  seemed  to  understand 
everything  that  was  said,  but  had  to  a  certain  extent  lost  the  memory  of 
words,  and  would  call  things  by  their  wrong  names ;  for  instance,  when 
the  fire  was  burning  particularly  brightly  he  said,  ''  How  bright  the  poker 
looks  !  "  Some  one  said,  "  You  mean  the  fire  ? "  "  Yes,"  he  said,  "  I  mean 
the  fire." 

Lichtheim  reports  a  case  of  lesion  of  the  paths  between  both  the 
auditory  and  the  visual  centers  and  the  concept  sphere,  with  an  interest- 
ing medico-legal  experiment.  Such  a  break  should  give  us,  according  to 
his  analysis,  loss  of  understanding  of  spoken  and  written  language,  with 
the  preservation  of  volitional  sjieech,  which  would,  however,  be  para- 
phasic,  and  of  vohtional  writing,  which  would  be  similarly  paragraphic ; 
also  with  retention  of  the  faculty  of  repeating  words,  of  reading  aloud,  of 

*  Bateman,  Aphasia,  etc.,  p.  169. 


APllAi>IA    AXD    OTHER   AFl'ECTIOSS   OF  SFKECIL.  279 

writing'  from  dictation,  and  of  copying'  words,  with,  however,  a  h)ss  of  in- 
telHgenee  for  what  is  repeated,  read  ahjud,  or  written  from  dictation.  The 
<?as(^  bears  out  fully  this  analysis.  Verbal  deafness  was  ])resent,  but  with 
little  or  no  dellciency  in  the  nuin's  vocabulary,  although  he  was  in  great 
difficulty  when  he  had  to  name  objects  shown  to  him;  he  could  repeat 
what  was  said  to  him  without  understanding ;  he  understood  nothing 
printed  or  hand-written ;  he  could  make  up  letters  into  words  and  could 
read  aloud  l)y  spelling,  but  the  sense  of  the  Avords  renudned  closed  to 
him.  His  other  losses  and  preservations  were  in  accordance  with  the 
analysis  just  given.  Word-deafness,  paraphasia,  paragraphia,  and  in- 
telligent comprehension  changed  markedly  for  the  l^etter ;  but  even  after 
much  improvement  writing  to  dictation  remained  obscure.  Lichtheira 
dictated  to  him  an  I  0  U  for  20,000  francs,  which  the  patient  allowed  the 
doctor  to  put  into  his  pocket ;  but  in  less  than  a  mouth  the  experiment 
with  the  due  bill  no  longer  succeeded.  This  case  and  that  reported  by 
Hun  illustrate  a  point  which  must  always  lie  borne  in  mind  when  giving 
testimony,  and  one  to  which  I  have  ah-eady  referred,  namely,  that  im- 
provement in  various  ways  both  on  the  impressive  and  expressive  sides 
often  takes  place  in  aphasie  cases. 

Starr*  has  reported  several  interesting  cases — one  of  paraphasia  pro- 
gressing to  total  aphasia,  in  which  the  patient  was  anxious  to  give  direc- 
tions about  fiuaucial  affairs  and  about  his  will,  and  although  he  knew 
what  he  wished  it  was  impossible  for  others  to  learn  his  desires  either 
"by  speech  or  writing.  Another  patient,  a  physician,  would  sometimes 
write  the  name  of  oue  drug  in  a  prescription  for  another,  and  was  also 
likely  to  \Yv\te  the  quantities  wrong,  so  that  he  never  failed  to  read  his 
prescriptions  several  times :  this  shows  another  peculiar  medico-legal 
phase  which  such  a  subject  may  have. 


MENTAL  INTEGRITY  AND   COIMPETENCY   OF   MOTOR  APHASICS. 

Commonly  and  correctly,  mental  integrity  and  competency,  whether 
considered  Avith  reference  to  the  deprivation  of  liberty,  the  care  of  an 
estate,  the  making  of  a  contract,  the  preservation  of  testamentary  capac- 
ity, or  other  questions  that  may  ai-ise  in  connection  wdth  aphasics,  are 
not  regarded  as  affected  by  the  existence  of  motor  aphasia — n(^t  even 
when  associated  with  considerable  paralysis  and  perhaps  even  with  other 
forms  of  aphasia  not  part  of  a  case  of  insanity ;  but  each  such  case 
ishould  be  studied  on  its  oavu  merits,  and  the  evidence  _/;>•(>  and  con  should 
be  carefully  sifted.  Ray,  Bastian.  Ferrier.  Hamilton.  Hughes.  Bateman, 
Kussmaul,  and  many  others  have  expressed  the  opinion  that  aphasia 
from  destruction  of  the  motor  speech  centers  does  not  of  necessity 
mentally  incapacitate  the  individual,  and  many  cases  have  been  recorded 
by  these  and  other  authors  to  illusti-ate  the  retention  of  mental  power 
hy  such  patients.  Even  for  motor  aphasics,  however,  general  conclusions 
are  not  sufficient,  as  such  cases  separate  themselves  into  several  classes 
according  to  the  site  aiul  extent  of  the  brain  disease  producing  them.  A 
sharp  distinction  must  be  nuide  Avith  reference  to  all  aphasics,  but  par- 
ticularly those  in  AA'hich  the  motor  type  predominates,  betAveen  having 

*  Starr,  Xcir  York  Medical  necord.  October  27,  1SS8. 


280  ^   SYSTEM  OF  LEGAL  MEDICINE. 

mental  power  and  being  able  to  make  known  this  possession  to  others  ^ 
between  the  capacity  to  wish  and  will  certain  things  and  the  ability  by 
speech,  writing,  or  pantomime  to  show  the  desire  and  intention.  In 
pure  motor  aphasia,  due  either  to  lesion  of  Broca's  convolution  or  the 
utterance  centers  at  the  base  of  the  central  convolutions,  or  of  both, 
the  patient  is  usually  able  to  make  his  wishes  and  purposes  kno^Ti, 
Usually  such  aphasia  is  associated  with  agraphia,  but  expressive  panto- 
mime is  likely  to  remain  in  some  degree,  so  that  the  patient  can  often 
communicate  intelligibly  with  others.  The  impressive  and  concept 
spheres  of  language  are  not  interfered  with,  and  if  any  clear  means  of 
expression  and  communication  remain,  the  capacity  and  competency  of 
such  a  patient  will  be  scarcely  questioned.  Cases  which  illustrate  this 
standpoint  are  to  be  found  in  aU  articles  and  treatises  on  aphasia,  and 
need  not  be  quoted.  Even  cases  of  pure  motor  aphasia  naay  be  some- 
times misunderstood,  if  care  is  not  taken  in  communicating  with  them. 
Bastian*  says  that  in  pure  agraphia  thought  is  least  of  aU  interfered 
with,  while  in  pure  aphasia  it  is  more  or  less  hampered,  because  the  non- 
revival  of  glossokinesthetic  impressions  seems  to  interfere  somewhat 
with  the  free  and  thorough  revival  of  words  in  other  functionally  related 
word  centers,  even  during  the  process  of  silent  thought.  Motor  agraphia 
is  usually  associated  with  aphasia  of  the  motor  type,  and,  like  the  latter,, 
is  also  variously  combined  with  conduction  or  even  conceptual  and 
sensorial  affections,  and  its  importance  will  of  course  depend  largely 
upon  its  combinations  and  complications. 

Cases  of  either  motor  aphasia  or  agraphia  of  pure  type  and  unasso- 
ciated  with  paralysis  are  rare.  By  far  the  most  common  association  is 
motor  aphasia  and  agraphia  combined  with  types  of  conduction  aphasia 
and  well-marked  hemiplegia.  These  hemiplegic  aphasics  easily  separate 
into  three  classes  with  reference  to  the  presence  and  persistence  of  the 
aphasia:  (1)  those  in  which  aphasia,  complete  or  nearly  complete  at 
first,  in  the  course  of  days,  weeks,  or  months  totally  or  almost  totally 
disappears ;  (2)  those  in  which  aphasia  is  nearly  or  quite  absolute  and 
remains  permanently;  (3)  those  which  improve  slowly,  and  largety 
through  a  tedious  process  of  training  and  reeducation.  The  nervous, 
wards  of  the  Philadelphia  Hospital  almost  always  contain  some  cases  of 
these  different  types. 

When  the  hemiplegia  persists  although  the  aphasia  passes  away,  the- 
lesions  are  most  probably  of  the  internal  capsule,  compressing  or  only 
partially  destroying  the  fibers  for  the  facial  centers.  The  patients  recover 
their  speech  because  of  the  escape  in  large  measure  both  of  projection 
and  commissural  fibers.  The  mental  integritj^  of  patients  of  this  class, 
after  the  apoplectic  period  is  always  retained,  and  is,  as  a  rule,  soon  easy 
of  determination.  The  ability  to  write  and  to  express  thought  by  panto- 
mime is  fidly  preserved  on  the  non-paralyzed  side,  and  to  some  extent,, 
when  the  paralj^sis  is  not  absolute,  the  paralyzed  Hmbs  may  be  made  to- 
do  service  in  expression. 

In  hemiplegic  aphasics,  in  which  the  aphasia  remains  nearly  or  quitfr 
absolute  and  permanent,  the  determination  of  the  mental  status  of  the 
crippled  individual  is  often  a  matter  of  great  difficulty.  Generally  the 
lesion  is  one  of  large  size,  involving  and  destroying  both  internal  and 

*  Bastian,  British  Medical  Journal,  vol.  ii.,  1SS7,  p.  934. 


APHASIA   AND    (JTIIKll   AFFECTWXS   OF  Hl'EKLll.  281 

external  capsules,  and  to  a  {greater  or  less  extent  both  striate  bodies 
and  tlie  insula ;  in  other  words,  one  which,  according  to  oiu'  best  lights, 
disrujjts  entirely  the  internuncial  tract  for  speech  and  also  largely  the 
commissures,  both  direct  and  iiulirect,  between  the  sensorial  and  motor 
centers  or  between  the  latter  and  the  center  for  concepts.  The  lesion, 
moreover,  is  often  so  close  to  the  cortex  for  speech  as  to  destroy  the 
commissures  which  would  otherwise  connect  the  left  hemisphere  with 
the  right  tlirough  the  callosum.  Although  motor  aphasia  and  motor 
paralysis  of  face  and  limbs  are  prominent,  the  ease  is  in  reality  one  of 
badly  mixed  type,  and  presents  phenomena  at  first  sight  as  confusing 
to  the  investigator  as  the  disturbances  of  thought  and  speech  are  to  the 
suffering  patient.  It  is  in  such  a  case  particularly  that  a  vast  difference 
exists  between  the  possession  of  thinking  power  and  the  ability  to  com- 
municate with  others.  As  a  rule  writing  and  pantomime  are  lost  in 
equal  degrees  with  speech ;  but  every  means  should  be  exhausted  and 
every  channel  of  communication  tested. 

So2ne  knowledge  of  the  most  frequent  methods  of  combination  in  the 
mixed  aphasias  will  be  of  service  in  attempts  at  the  solution  of  the 
medico-legal  problems  of  speech.  Brain  lesions,  usually  vascular,  are 
likely  to  extend  over  areas  and  tracts  wliich  are  associated  in  function- 
ing, and  have,  in  accordance  vdih.  a  general  law,  a  more  or  less  common 
source  of  blood-supply.  Different  varieties  of  psychical  bhndness  and 
deafness,  partial  or  complete,  may  occur  together;  motor  aphasia, 
agraphia,  and  amimia,  partial  or  complete,  are  usually  associated  with 
paraphasias ;  and  frequently  partial  word-deafness  is  found  in  conjunc- 
tion with  one  or  se^-eral  of  the  varieties  of  motor  defect  in  exj)ression. 
Total  sensory  and  motor  aphasia  is  sometimes  observed,  and  is  of  course 
accompanied  by  the  completest  form  of  speech,  graphic,  and  pantomimic 
disorder — complete  aphasia,  agraphia,  and  amimia. 

Close  studies  of  these  compound  cases  Avill  doubtless  better  enable  us 
after  a  time  to  separate  them  into  different  classes,  guided  by  locahza- 
tion  facts  and  theories ;  to  distinguish  cases  in  which  either  the  direct 
sensorimotor  or  the  concept-motor  commissures,  or  both,  or  the  hemi- 
spheric commissiu'es,  are  damaged  at  the  same  time  that  the  lesion  at- 
tacks cortical  centers  and  cortico-bulbar  tracts.  The  path  from  concept 
to  motor,  or  from  auditory  to  motor,  centers  is  certainlv  frequently 
broken,  and  probably  most  frequently  near  the  motor  end  of  the  hue. 
Pure  or  almost  pm-e  cases  of  concept-motor  aphasia  have  been  reported 
in  considerable  number. 


PSEUDOBULBAR  .VXD  BULBAR  AFFECTIONS  OF  SPEECH. 

The  form  of  iufracortical  affection  of  speech  which  results  fi-om  lesion 
of  the  tract  or  tracts  connecting  the  cortical  centers  with  the  nuclei  of 
the  bulb  and  spiiuil  cord  is  of  considerable  importance  because  of  the 
frequent  disturbance  either  by  pressure  or  destruction  of  this  portion  of 
the  cerebrum.  In  many  cases  of  hemiplegia,  aphasia,  at  first  very  i)romi- 
neut  and  positive,  after  a  time  disai)pears  in  large  part  or  even  abuost 
entirely,  the  paralysis  of  the  leg  aiul  arm  remaining  very  pronounced. 
Some  of  these  eases  are  to  be  explained  by  the  fact  that  the  intracerebral 
facial  tracts  are  only  affected  by  pressure,  and  in  others,  even  when  they 


282  ^   SYSTEM  OF  LEGAL  MEDICINE. 

are  more  or  less  destroj^ed,  the  opposite  hemispliere  assumes  the  work 
of  both.  The  common  view  is  that  the  bilateral  movements  which  occur 
during;  speech  may  be  innervated  from  each  hemisphere.  More  or  less 
complete  destruction  of  the  fibers  which  connect  the  orolingual  and  other 
facial  areas  of  the  cortex  with  the  nuclei  of  the  various  nerves  concerned 
Avith  articulation  and  phonation  does  sometimes  give  a  disorder  of  speech, 
which  has  been  variously  described  as  pseudobidbar  paral}- sis,  labio-glos- 
sopharyngeal  paralysis  of  cerebral  origin,  aphemia,  etc.,  and  eases  have 
been  reported  by  KirchofP,  Ross,  Hobson,  Bastian,  the  writer,  and  others. 
Two  such  cases  will  be  given  in  the  section  on  pantomime.  These  patients 
articulate  with  difficulty ;  paresis  or  paratysis  of  the  tongue  is  present ; 
labials  and  gutturals  and  Unguals  may  all  be  troublesome  to  pronounce ; 
drawing  of  the  face  will  usually  be  present ;  swallowing  may  be  difficult ; 
the  movements  of  the  jaw  may  be  impaired;  a^nd  drooling  is  a  frequent 
sj'^mptom.  In  such  cases  interference  with  speech  is  sometimes  extreme, 
amounting  almost  to  complete  speechlessness.  While  such  a  train  of 
symptoms  usually  accompanies  a  generalized  hemiplegia,  it  is  occasion- 
ally observed  unconnected  with  paralysis  in  parts  other  than  the  face. 

This  pseudobulbar  parah'sis  is  a  more  decided  and  permanent  affec- 
tion when  the  result  of  bilateral  disease,  but  a  form  of  it  can  occur  from 
a  deep-seated  lesion  confined  to  the  left  hemisphere.  Strictly  speaking, 
Broca's  convolution  is  not  du*ectly  connected  with  the  basal  nuclei,  but 
indirectly  it  is  through  the  utterance  or  glosso-labio-pharyngolaryngeal 
cortical  centers,  a.nd  the  larger  portion  of  the  fibers  which  go  down  from 
these  centers  to  the  bulb  pass  by  way  of  the  left  hemisphere,  although  a 
partial  decussation  probably  takes  place.  If  a  commissure  connects  the 
speech  or  utterance  regions  of  the  two  hemispheres,  it  must  be  compara- 
tively close  to  the  cortex,  and  its  destruction,  as  well  as  of  the  fascicu- 
lus to  the  bulb,  would  accomit  for  some  of  the  infracortical  speech  or 
articulatory  disturbances. 

According  to  Lichtheim*  we  are  compelled  to  assimie  that  only  a 
short  extent  of  the  efferent  tract  from  Broca's  centers  is  so  constructed 
as  to  give  rise,  on  being  injured,  to  real  aphasie  disturbances ;  and  we 
shall  therefore  have  to  look  also  for  the  lesion  of  aphasia  without  agraphia 
in  the  white  matter  of  the  hemispheres. 

Anarthria,  or  disturbance  in  articulation,  rather  than  a  genuine  apha- 
sia, accompanies  pseudobulbar  or  labio-glossopharyngeal  paralysis  of  cere- 
bral origin.  The  most  marked  examples  are  due  to  bilateral  lesions  or 
degenerations.  Whether  unilateral  or  bilateral,  all  cerebral  centers  and 
commissural  channels  are  undisturbed ;  volitional  sjjeech,  word  repetition, 
and  reading  aloud  are  lost  or  greatly  impaired  simply  because  of  inter- 
ruption to  speech  impulses  in  the  outgoing  roadways  below  the  cortex. 
Mental  capacity  and  competency  need  not  be  in  the  least  diminished,  as 
the  patient  preserves  his  receptive  and  conceptive  faculties  and  large 
powers  of  communication  by  means  of  pantomime  and  writing  unless 
paralysis  of  face  and  limbs  accompany  the  aphasia. 

In  true  bulbar  paralysis,  in  which  the  changes  iu  articulation  are 
sometimes  slight  and  at  others  so  complete  as  to  almost  abolish  articu- 
late speech,  mental  soundness,  if  the  cases  are  uncomplicated,  is  not  in 
any  degree  impaired,  and  various  methods  of  expression  and  communi- 

*  Lichtheim,  Brain,  January,  1885,  pp.  481,  482. 


ArUAiilA   AXD    OTUElt  AFFIXTJOSS   OF  SPEECH.  283 

cation  remain.  "  As  in  the  course  of  these  degenerative  changes  one 
ganglion-eell  after  another  is  sh)wly  destroyed  in  the  bulbar  nuclei,"  saj's 
Kussmaul,*  "we  perceive  consonants  and  vowels  successively  crumbling 
away,  as  it  were,  from  the  patient's  speech,  while  his  intellectual  powers 
may  be  perfectly  retained." 

The  various  but  allied  forms  of  speech  disturbance  which  result  from 
insular  sclerosis  and  foeal  lesions  of  other  sort  in  the  intracere])ral  tracts 
are  not  necessarily  accompanied  with  any  loss  of  mental  strength  or  clear- 
ness, although,  as  is  well  known,  mental  changes  are  somewhat  common 
in  this  affection  because  of  its  diffuse  and  destructive  character.  It  is 
scarcely  necessary  to  refer  to  the  peculiar  varieties  of  speech  defect  found 
in  this  well-known  disease,  which  have  been  Avell  described  under  a  vari- 
ety of  names  such  as  di-awling,  sj'llabic,  scanning,  staccato,  and  hesitating. 

SPEECH  DISTURBA^^CES  ASSOCIATED  WITH  INSANITY. 

The  study  of  speech  disturbances  which  are  associated  with  various 
forms  of  insanity  would  need  an  article  of  considerable  length  for  their 
full  discussion.  I  can  scarcely  more  than  refer  to  them.  As  has  been 
said  by  Dr.  Hughes,  aphasia  dissociated  from  marked  mental  impaii-ment 
is  of  more  frequent  occurrence  than  in  association  with  evident  insanity ; 
so  that  in  a  case  of  suspected  mental  disease  the  burden  of  proof  will  fall 
on  those  who  might  maintain  the  coexistence  of  mental  aberration,  and 
the  legal  presumption  would  be  in  such  a  case  in  favor  of  sanity.  While 
this  is  true  it  must  not  be  lost  sight  of  that  aphasia  is  found  among 
those  who  are  clearly  insane.  Broca's  first  two  cases  were  observed  in 
an  institution  devoted  to  the  treatment  of  mental  disease,  and  not  a  fcAv 
of  the  recorded  cases  have  been  observed  in  hospitals  for  the  insane. 
Every  physician  in  charge  of  an  institution  of  this  character  should 
carefully  inquire  into  the  history  and  symptomatology  of  cases  showing 
special  forms  of  speech  disturbance.  The  two  cases  referred  to  by  Kuss- 
maul will  be  remembered — patients  suffering  from  aphasia,  but  not  in- 
sane, and  yet  confined  in  an  asylum. 

Probably  in  paretic  dementia  and  senile  dementia  the  study  of  speech 
defects  has  more  diagnostic  and  medico-legal  value  than  in  any  other 
of  the  well-recognized  types  of  insanity.  In  the  early  stages  of  the  former 
disease  it  may  serve  to  make  clear  the  true  nature  of  the  case ;  in  the 
latter  affection  it  may  be  of  decisive  importance  in  the  determination  of 
questions  of  competency.  In  mania,  melancholia,  paranoea,  katatonia, 
idiocy,  and  imbecility  the  peculiarities  of  speech  might  have  some  bear- 
ings upon  medico-legal  problems  in  connection  with  the  diagnosis  of  the 
nature,  depth,  or  stage  of  the  affection. 

About  the  hallucinations  and  delusions  of  aphasics  much  of  interest 
might  be  written.  The  hallucinations  are  usually  of  hearing  and  sight, 
and  may  in  not  a  few  cases  be  dependent  upon  irritation  of  sensory  cen- 
ters ;  while  various  delusional  states  may  have  their  origin  in  disease  of 
both  sensory  and  concept  centers,  or  in  the  disruption  of  various  lines  of 
communication  between  the  different  areas  of  the  brain  concerned  with 
speech. 

A  consideration  might  be  here  in  place  of  the  inhibitory  speech  cen- 

*  Kussmaul,  oj).  cit.,  p.  65-i. 


284  ^   SYSTEM  OF  LEGAL  MEDICIXL. 

ters,  or  centers  for  abstract  tliinking,  wliicli  I  have  inelnded  in  the  list 
of  centers  taking  part  in  the  phenomena  of  sj^eeeh,  bnt  ■u'hich  are  not 
nsnally  so  included.  The_v  are  probably  located  in  the  prefrontal  region. 
Hnghlings  Jackson,*  Mercier,  and  others  hold  that  anterior  to  the 
Rolandic  motor  region  are  the  highest  motor  centers,  and  that  these  "with 
corresponding  sensory  centers  make  np  the  highest  level  of  the  central 
nervous  system.  Jackson  contends  that  these  higher  centers  represent 
all  parts  of  the  body ;  and  Mercier  that  the  highest  nerve  processes  which 
form  the  substrata  of  the  most  elal)orate  mental  operations  represent  at 
the  same  time  not  only  the  most  elaborate  forms  of  conduct  and  mus- 
cular movements,  but  also  every  part  of  the  organism  to  some  degree. 
Accepting  such  doctrines,  speech,  like  every  other  function  of  the  body, 
must,  of  coiu'se,  be  influenced  by  anything  which  aifeets  these  highest 
centers.  Affections  of  speech  due  to  lesions  of  these  prefrontal  areas  are 
a  part  of  the  general  mental  impairment  which  goes  ^vith  the  destruction 
of  this  region  ;  and  the  mental  status  of  the  individual  will  be  recognized 
as  much  by  other  phenomena  as  by  those  of  speech. 

APHASIA   AND   EPILEPSY. 

The  association  of  aphasia  with  epilepsy,  and  the  occurrence  of  what 
might  be  termed  an  ei3ileptic  or  epileptiform  aphasia  "^dthout  spasm — or 
at  least  without  the  usual  type  of  convulsion  with  imconsciousness — may 
have  important  medico-legal  bearings.  Distiu-bances  of  speech  in  connec- 
tion with  epileptic  attacks  are,  of  coui'se,  very  common,  and  may  occur 
before  or  after  or  even  dming  a  fit,  when  loss  of  consciousness  is  not 
profound.  Sometimes  a  seizure  is  preceded  by  muttering  or  confusion 
of  speech,  by  "  thickness  of  tong-ue,"  by  utterance  of  certain  expressions, 
by  an  unusual  talkativeness,  or  by  an  absolute  ina.bihty  to  talk.  The 
aura  of  the  attack  may  be  a  sj)eech  disorder.  It  is  not  worth  while  to 
go  into  details  as  to  the  numerous  perversions  of  speech  and  thought 
which  so  evidently  follow  epileptic  attacks ;  they  are  simply  the  e^ddences 
of  exhaustion  of  the  cerebral  mechanism  ^vhich  has  resulted  from  a  ter- 
rible explosion  of  nervous  energ}^  Avhieh  had  occurred  during  the  fit.  In 
addition  to  these  affections  of  speech,  however,  are  others  of  rarer  occur- 
rence and  of  special  interest.  In  some  of  these  the  aphasia  itself  is  the 
fit,  just  as  we  may  have  instead  of  a  motor  paroxysm,  which  is  the  usual 
epileptic  manifestation,  a  substitutional  attack  of  mania,  of  vertigo,  of 
pain,  of  running,  or  other  automatism. 

The  presence  or  absence  of  speech  disturbances  ^-ith  conscious  epilep- 
tic automatism — wliich  is  perhaps  a  somewhat  contradictory  expression 
— may  have  some  medico-legal  importance.  Stevens  and  Hughes  t  have 
reported  such  a  case,  and  many  more  as  similar  are  to  be  found  in  books 
and  journals.  This  patient,  a  i^hysician,  on  several  occasions  got  up  in 
the  night,  dressed  himself,  and  went  out-of-doors  to  look  at  his  stock,  or 
perhaps  simply  mthout  any  purpose.  During  part  of  the  time  at  least 
lie  realized  that  lie  was  doing  something  which  he  should  not.  He  had 
had  many  real  epileptic  seizures  preceding  these  attacks.     He  was  put 

*  Huglilings  Jackson,  Xew  Yorl:  Medical  Eecorch  vol.  xxxvi..  Aiigust  31,  1889,  pp. 
227,  228. 

t  Stevens  and  Hughes,  Alienist  and  Neurologist,  April,  1880. 


APHASIA   AND    OTJIEIt  AFFECTIONS   OF  SFEKCII.  Ov^-; 

under  treatment  and  greatly  improved,  but  on  another  occasion  in  a 
similar  seizure  he  was  asked  a  question  which  he  understood  perfectly 
l)ut  eouhl  not  answer,  althoug'h  he  continued  to  talk  for  ahout  twenty 
minutes  attem})ting  to  explain  what  he  was  trying'  to  say.  The  night 
following'  this  incident  he  had  a  severe  ej)ileptic  attaitk.  He  afterward 
could  recall  mucdi  of  what  he  had  said  and  done  when  in  this  confused 
automatic  state.  The  reporters  of  the  case  ask  what  would  have  been 
the  result  had  some  acts  been  done  by  this  patient  during  his  apparently 
conscious  sommxmbulism,  something,  for  instance,  involving  him  in 
pecuniary  obligation,  as  the  signing  of  a  deed,  or  the  doing  of  any 
act  making  him  liable  to  the  law.  Every  ueiu-ologist  of  experience  has 
seen  similar  cases, 

SIJIULATED,  JIDIETIC,  AND  MISCELLANEOUS   AFFECTIONS   OF   SPEECH. 

The  nature  of  some  cases  of  sudden  loss  or  abrupt  disturbance  of 
speech  is  sometimes  obscure  and  needs  careful  investigation.  The  affec- 
tion might  be  absolutely  assumed  or  malingered,  as,  for  instance,  where 
it  is  part  of  a  scheme  for  dissimulation  of  insanity,  or  where  it  is  shammed 
to  present  a  more  serious  picture  in  a  litigation  case ;  or  such  loss  or 
disturbance  of  speech  might  be  neuromimetic  or  hysterical  but  not 
absolutely  simulated. 

Many  years  ago  I  was  sent  for  in  haste  to  see  a  young  woman  who 
had  suddenly  become  perfectly  speechless,  causing  great  consternation 
to  her  lover  and  the  other  residents  of  the  house.  No  facial  or  limb 
paralysis  could  be  made  out,  and  she  had  none  of  the  usually  associated 
j)henomena  of  either  an  apoplectic  or  an  epileptic  attack.  This  abrui)t 
loss  of  speech  had  come  on  aftei-  a  quarrel  with  her  lover,  in  which  both 
he  and  she  had  exhibited  violent  rage,  although  no  physical  force  had 
been  used.  This  case  was  j^robably  one  of  hysterical  aphasia,  the  result 
of  nervous  excitement  attendant  upon  the  quarrel.  The  patient  recov- 
ered as  abruptly  as  she  had  been  attacked.  A  form  of  mutism  is,  as  is 
well  known,  quite  common  as  a  phase  of  hysteria,  but  the  cases  here 
referred  to  are  those  in  which  the  loss  of  speech  comes  on  as  a  sudden 
•attack. 

The  simulation  of  dumbness  by  criminals  or  others  should  not  be  over- 
looked, as  it  is  in  fact  a  simulation  of  aphasia  or  in  some  cases  of  both 
aphonia  and  aphasia.  It  may  be  resorted  to  by  criminals  feigning  to  be 
insane  in  order  to  escape  the  consequences  of  theii*  crimes,  or  bj''  prison- 
ers to  avoid  duties  and  punishments.  Hay*  mentions  the  case  of  a  man 
who  had  cut  off  his  wife's  head  and  had  or  assumed  the  demeanor  of  an 
imbecile.  Among  other  manifestations  he  carried  a  piece  of  wood  alxmt 
with  him,  which  he  represented  by  signs  to  be  a  swoi-d.  He  would  not 
speak  or  answer  any  questions  except  by  now  and  then  repeating  the 
word  "cabbage"  without  any  meaning.  Another  French  homicide,  who 
was  adjudicated  insane,  would  not  answer  questions,  although  he  heard 
and  understood  them.  Jean  Gerard  murdered  a  woman  at  Lj^ons  in 
1829,  and  immediately  after  his  arrest  ceased  to  speak  altogether  and 
appeared  to  be  in  a  state  of  fatuity.  The  use  of  the  actual  cautery  for 
several  days  brought  him  to  terms,  and  after  some  urging  he  spoke, 

*  Kay,  ]\Icilical  JurisprudcHCc  of  lusanilij. 


286  ^  systi:m  of  legal  medicine. 

declaring  his  innocence  of  the  crime  with  which  he  was  charged.  An 
Itahan  criminal  became  insane  soon  after  he  had  been  betrayed  by  his- 
accompUces,  and  to  any  question  whatever  he  merely  uttered  the  words 
''priest,  book,  crown,  crncifix."  Many  details  are  connected  with  this 
case,  but  it  was  finally  decided  that  he  was  insane.  It  is  not  impossible 
that  he  may  have  been  insane  and  also  simulated  some  of  his  symptoms. 

In  suspected  shamming  of  dumbness  or  of  aphasia  the  genuineness 
of  the  phenomena  should  be  patiently  tested  from  the  standpoint  that 
the  defect  of  speech  might  be  due  to  the  mental  state,  that  is,  an  aphasia 
or  dysphasia,  and  also  from  the  standpoint  that  it  might  be  primary, 
that  is,  a  true  aphasia  or  dysphasia.  The  tests  for  the  determination  of 
the  presence  of  insanity  or  its  simulation  should  be  applied  as  far  as 
possible,  resorting  to  surprises,  strategy,  and  perhaps  even  in  some  cases 
to  anesthesia  or  to  stern  methods.  The  apparent  aphasia  or  apraxia 
should  also  be  tested  and  studied  as  is  any  ordinary  case  of  this  alfec- 
tiou  in  the  sane.  Word-deafness,  word-blindness,  alexia,  dyslexia,  motor 
aphasia,  and  agraphia  should,  if  possible,  be  investigated  and  included  or 
excluded ;  and  the  existence  or  non-existence  of  accompanpng  paralysis^ 
anaesthesia,  hemianopsia,  etc.,  should  be  given  full  weight. 

The  disease  known  as  ecliolalia  or  coprolalia,  and  by -various  other 
names,  might  have  some  medico-legal  importance.  This  is  an  affection 
in  which  convulsive  or  choreic  movements  are  associated  with  a  sudden 
explosion  of  speech.  The  patient,  with  a  grimace,  contortion,  or  violent- 
movement  of  some  kind,  suddenly  bursts  into  an  obscene,  profane,  or 
absurd  expression.  This  expression  may  be  the  echo  of  something  over- 
heard— hence  the  name  echolalia — or  it  may  be  a  spontaneous  outcry. 
It  is  conceivable  that  such  a  patient  might  be  arrested  for  the  use  of 
obscene  or  insulting  language  in  the  presence  of  others,  and  physicians 
and  jurists  should  therefore  bear  in  mind  that  such  a  disease  exists,  and- 
that  the  impulse  to  burst  forth  in  this  way  is  sometimes  irresistible.  It 
is  not  simply  an  hj'sterical  affection,  controllable  and  curable,  but  is  a- 
true  monomania,  the  affection  of  speech  being  beyond  the  patient's  voh- 
tion.  One  patient  of  mine,  a  boy  about  twelve  years  of  age,  would  at 
times  without  warning,  in  a  street-car  or  other  pubHc  places,  as  well  as 
in  private,  suddenly  give  utterance  to  a  filthy  expression  two  or  three 
times,  accompanjdng  it  with  a  violent  movement  of  the  head  and  shoul- 
ders and  one  arm.  Another  patient,  a  lady  of  good  education  and  fine 
personal  appearance,  would  in  the  midst  of  a  conversation,  or  on  intro- 
duction to  another,  or  at  any  most  inopportune  time,  suddenlj^  with  vio- 
lent gesticulation  shout,  "  Damn  it !  Damn  it ! "  Gilles  de  la  Tourette^ 
Dana,  Seguin,  and  others  have  reported  numerous  cases  of  this  kind, 
and  the  affection  certainly  has  a  possible  medico-legal  aspect. 

The  following  quotation  from  Hughes*  may  serve  to  cover  some 
points  with  reference  to  the  medico-legal  aspects  of  affection  of  speech 
not  otherwise  included  in  the  present  paper : 

"  The  hysterical,  the  choreic,  the  cataleptic,  the  emotional,  the  hj^er- 
emic,  and  reflex  forms  of  speech  failure  have  neither  distinct  clmical  sig- 
nificance, nor  are  they  likely  often  to  have  medico-legal  importance  sep- 
arate from  the  diseases  mth  which  they  may  be  associated.  They  need 
not,  therefore,  be  considered  here,  and  we  mention  them  mainly  to  ex- 

*  Hughes,  Alienist  and  Neurologist,  vol.  i.,  No.  3,  July,  1880,  pp.  315,  316. 


Al'UASIA    AXD    OTHER   AFFECTIONS   OF  SI'EECII.  287 

elude  tlieni,  as  wo  likewise  do  the  speeclilessiiess  of  iiiglitmare.  Marc 
and  others,  however,  have  noted  the  temporary  impairment  of  the  mental 
faeulties  in  ehorea,  and  the  defect  in  the  speech  power  in  this  disorder 
is  prol)al)ly  as  much  depeiulent  on  cere1)i-al  disorder  implicatinj^  the 
speeeh  center  along  with  other  portions  of  the  cortex  as  on  disturbances- 
of  the  motor  area  for  the  oi-gans  of  articulation.  There  are  circumstances^ 
too,  under  which  aphasia  occurring  in  the  coiu-se  of  cerebi-al  hyi)eremia 
might  have  corroborative  significance  in  a  question  of  doubtful  sanit3^ 

"The  occasioual  aphasia  of  drunkenness  has  never  been  pathologic- 
ally defined  with  sutficient  distinctness.  It  is  often,  no  doubt,  a  sort 
of  iucom})lete  and  transient  glossolabial  paralysis,  lil^e  the  other  forms 
of  incoordination  seen  in  inebriates,  or  the  peculiar  and  more  permanent 
defects  of  speech  displayed  by  general  paralytics.  This  latter  form  of 
speech  defect,  also,  need  not  be  considered  apart  from  the  graver  disease 
with  which  it  is  associated,  and  which  has  other  characteristic  signs. 
Nor  need  we  note  any  of  the  giossoplegias  causing  speech  defect. 

"  The  momentary  speechlessness  sometimes  occurring  in  persons  over- 
come with  fright  or  profound  surprise  at  being  the  nnwilling  or  unex- 
pected witnesses  of  some  horiible  tragedy  might  possibly  be  considered 
where  an  innocent  person  is  indicted  as  partkeps  criminis  from  the  fact 
of  his  being  present  and  uttering  no  protest  or  cry  of  alarm  ;  but  in  such, 
cases  the  proper  explanation,  I  believe,  has  always  been  and  is  still  likely 
to  be  made  and  received,  so  well  understood  is  the  fact  by  the  common 
mind  that  intense  fear  may  for  a  time  paralyze  the  power  of  speech  as 
well  as  motion." 

DISORDEES   OF  PANTOMIME   OCCURRING  AJMONG  APHASICS. 

In  several  places  in  this  chapter  the  subject  of  pantomime  has  been 
referred  to  incidentally,  but  it  is  of  such  great  importance  medico-legaUy 
and  it  has  received  so  little  attention  from  writers  that  it  has  seemed 
best  to  consider  it  in  a  separate  section. 

Pantomime  is  the  representation  of  ideas  by  action  and  movement ; 
it  is  an  intellectual  act ;  according  to  Hughliugs  Jackson  it  differs  from 
gesticulation  as  a  proj^osition  does  from  an  oath,  although  the  tenns 
gesture  and  pantomime  are  frequently  used  almost  interchangeably. 
Aminiia  and  paramimia  are  terms  which  have  a  corresponding  import, 
as  regards  pantomime,  to  aphasia,  paraphasia,  paralexia,  etc.,  with  refer- 
ence to  speech.  We  may  have  a  jargon  of  signs  and  motions  as  well  as 
of  Avords  and  of  sounds ;  we  may  have  a  sensory  or  receptive  and  a  motor 
or  emissive  amimia ;  sensory  amimia  is  in  fact  a  form  of  apraxia.  Pan- 
tomimic disorders  may  be  mixed,  combined,  or  associated ;  we  may  have 
all  blendings  of  them  just  as  we  have  the  ordinary  speech  disturbances. 
A  study  of  the  losses  and  disorders  of  pantominu^  will  often  be  of  great 
assistance  to  the  physician  in  diagnosis,  and  in  sonu^  medico-legal  cases, 
decision  will  largely  hinge  upon  the  consideration  of  the  presence,  absence, 
or  disturl;)ance  of  intelligent  pantomime.  Different  and  conflicting  inter- 
pretations are  too  often  given  to  p;nit(unime  observed  among  apliasics; 
every  ease  of  aphasia  should  be  studied  for  itseK  as  to  pantomime.  Loss 
or  impairment  of  pantomime  is  in  many  cases  proportionate  to  the  dis- 
turbance in  speech,  but  the  two  do  not  always  go  hand  in  hand,  and 
some  patients  recover  pantomimic  power  more  speedily  than  ordinary 


288  ^   SYSTEM  OF  LEGAL  MEDICINE. 

speecli.  If  the  visual  centers  or  entering  visnal  tracts  are  destroyed,  the 
patient  will  not  be  able  to  use  sight  in  the  execution  of  manual  or  other 
forms  of  pantomime  in  so  far  as  they  may  be  dependent  upon  vision. 
Even  impairment  or  destruction  of  the  enteiing  auditoiy  tracts,  or  of 
the  centers  for  auditory  images,  might  impair  pantomime  which  would 
otherwise  be  called  out  in  response  to  sounds  and  words  heard.  The 
most  distinctive  interference  with  pantomime  will,  however,  be  from 
destruction  of  the  center  for  propositionizing  and  of  the  tracts  connect- 
ing it  with  the  concept  centers  on  the  one  side  or  the  centers  for  move- 
ments of  the  Umbs  or  face  on  the  other,  or  from  the  destruction  of  the 
concept  areas  and  their  commissures.  Some  of  the  most  interesting  cases 
of  aphasia  associated  with  impairment  or  destruction  of  pantomimic  or 
gesticulatory  speech  indicate  differences  both  in  the  form  of  the  disorder 
and  in  the  site  and  extension  of  the  lesion  causing  them.  In  an  aphasic 
who  nodded  affirmatively  with  the  head  when  she  wished  to  answer  in 
the  negative,  and  used  two  fingers  to  express  four,  and  made  similar 
mistakes  of  pantomime,  a  cyst  was  found  destroying  a  groat  part  of  the 
third  left  frontal  convolution,  the  entire  left  island,  and  the  neighboring 
medullary  substance  and  anterior  third  of  the  corpus  striatum.*  This 
patient  knew  that  she  expressed  herself  wi'ongiy,  and  the  disorder  was 
therefore  not  amnesic ;  but  many  amnesic  cases  have  been  reported. 

In  nine  cases  of  aphasia  or  pseudo-aphasia  which  were  investigated 
"hj  me,  notable  differences  and  peculiarities  in  pantomime  were  presented 
by  the  patients. 

In  one  case  of  brachiocrural  monoplegia  almost  complete  motor  apha- 
sia with  marked  preservation  of  pantomime  was  present ;  in  a  hemiplegic 
with  convulsions,  word-blindness,  verbal  amnesia,  and  motor  aphasia, 
there  were  marked  sensorimotor  disturbances  of  pantomime  ;  in  a  third 
case,  one  of  right  hemiplegia  and  nearly  complete  aphasia  chieflj^  of  the 
motor  type,  the  pantomime  was  varied  and  uncertain ;  a  fourth  case  was 
one  of  right  hemiplegia  with  marked  contractures,  complete  aphasia  of  the 
mixed  type  with  a  single  recurring  utterance,  and  almost  complete  amimia ; 
a  fifth  was  a  case  of  rigid  hemiplegia,  paralysis  of  the  face,  almost  total 
sensorimotor  aphasia,  and  obstinacy  and  energetic  emotional  gesticula- 
tion. In  a  sixth  case  of  marked  hemiplegia  of  gradual  development,  with 
motor  aphasia  and  anarthria,  only  a  slight  degree  of  loss  of  pantomime 
was  shown ;  while  case  seven,  one  of  right-sided  pseudobulbar  paralysis, 
with  anarthria  and  preservation  of  writing  ability  with  the  left  hand, 
exhibited  also  full  preservation  of  pantomime.  Case  eight  was  an  ex- 
ample of  right-sided  pseudobulbar  paralysis  and  ophthalmoplegia,  with 
anarthria,  marked  orolingual  paresis,  and  full  preservation  of  pantomime, 
but  with  considerable  mental  apathy.  The  ninth  and  last  case  recorded 
was  one  of  double  hemiplegia  from  successive  lesions  on  the  right  and 
the  left  side  of  the  brain,  with  absolute  abolition  of  speech  and  panto- 
mime. 

The  study  of  pantomime  may  become  an  important  diagnostic  aid  in 
fijxing  subcortical  lesions,  and  particularly  the  position  of  a  subcortical 
lesion  with  reference  to  its  distance  from  the  cortex.  Some  of  the  cases 
detailed  showed  that  when  the  lesion  was  entirely  in  the  straits  between 
the  ganglia,  pantomime  was  either  not  lost  or  soon  entirely  regained. 

*  Peri'oud,  cited  by  Kussmaul  in  Ziemssen's  Cyclopcedia. 


jrUA6lA   AM)    OTHER   AFFECTIONS   OF  SPEECH.  289 

The  speech  defect,  as  has  been  stated,  is  of  the  nature  of  an  anartln-ia 
or  pseiid()l)ull)ar  affection,  and  a  diagnostic  point  is  tlie  ability  of  sn<-h 
patients  to  throw  even  into  the  paralyzed  members  some  volition,  as  in 
the  two  following  cases : 


Eight-sided  Pucudohulhar  Paralysis — Anmihria — Preservation  of  Writing 
Ahilifij  with  the  Left  Hand — Preservation  of  Pantoniime. 

F.  G.,  aged  tljirty-tive  years,  a  salesman,  after  an  attack  of  the  gi-ippe 
in  1889,  on  awaking  one  morning  found  that  he  was  i)aralyzed  in  the 
right  leg,  arm,  and  face,  and  was  nearly  speechless.  He  continued  in 
this  condition  for  four  months,  during  which  time  he  was  oidy  able  to 
say  *'  _yes."  Speech  steadily  improved  after  this.  He  "vvas  admitted  to  the 
Philadelphia  Hospital  in  September,  1891.  His  paralysis  had  remained 
about  the  same,  but  his  speech  had  gTadually  improved,  and  when  he 
w^as  admitted  to  the  hospital  he  could  speak  as  well  as  usual ;  but  about 
three  weeks  after  admission  his  speech  again  suddenly  became  impau'ed, 
and  at  the  same  time  he  complained  that  his  jaw  felt  stiff.  He  talked  in 
a  slow,  calculating,  hesitating  manner,  as  though  it  was  difficidt  to  articu- 
late and  enunciate  the  words  he  knew.  A  few  days  later  this  disorder  of 
speech  cleared  up  somewhat,  but  shortly  afterward  became  pronounced, 
and  has  remained.  His  condition  as  to  speech,  "when  examined  by  me 
October  28th,  was  as  follows :  He  understood  w^ords  spoken  or  read  to 
him,  also  printed  or  written  text,  and  could  read  aloud,  but  read  as  he 
spoke — in  a  peculiarly  slow,  hesitating  manner.  He  had  voluntary- 
speech,  but  it  was  impaired  in  the  same  manner  as  his  ability  to  read ; 
he  repeated  from  dictation  more  faintly  than  he  read  and  tallied. 

He  had  no  paresis  in  the  upper  distrilmtion  of  the  facial  nerve.  He 
could  not  draw  up  the  right  side  of  the  mouth,  and  eoiUd  not  elevate  or 
depress  the  right  lip  as  w^ell  as  the  left ;  the  platysma  movements  of  the 
right  side  were  also  impaired.  The  tongue  showed  inefficiency  and  want 
of  rapidity  and  strength  in  its  movements.  When  tlunist  out  it  went  a 
little  to  the  left,  arching  slightly,  the  convexity  of  the  curve  being  upward 
and  a  httle  to  the  left ;  the  inner  half  of  the  right  side  of  the  tongue  was 
arched,  while  the  outer  was  depressed.  The  right  side  of  the  tong-ue 
seemed  to  be  somewdiat  atrophied,  and  in  consecpience  of  this  the  con- 
tractions of  the  lingual  muscles  were  imperfect  and  changed  the  usual 
contours  of  this  organ.  His  voice  had  a  nasal  twang.  He  had  a  diffi- 
culty in  swallowing  liquids,  sometimes  regurgitating. 

The  tendon  and  muscle  reflexes  were  exaggerated,  and  front  tap  was 
present.  Marked  ankle-clonus  was  elicited  when  obtained  with  the  leg 
extended.  The  tendon  and  muscle  jerks  were  well  marked  in  the  left  leg, 
but  no  clonus  was  present.  He  had  no  sensory  losses  or  disturbances 
anywdiere.  Before  he  was  paralyzed  he  wrote  ^\\i\\  his  right  hand  ;  since 
his  attack  he  had  taught  himself  to  write  very  well  ^^-ith  his  left  hand. 

His  right  arm  was  almost  totally  paralyzed,  but  he  had  some  elbow 
and  metacarpal  and  phalangeal  flexion.  Paralysis  of  the  lower  extrem- 
ity was  very  decided,  but  not  as  complete  as  in  the  upper,  and,  like  that 
in  the  upper,  it  was  of  the  distal  rather  than  of  the  proximal  type.  The 
movements  below  the  knee  were  totally  paralyzed,  as  was  also  the  sar- 
torius  movement,  or  if  any  power  was  retained  in  the  sartorius  it  was 


290  ^   SYSTEM  OF  LEGAL  MEDICINE.     ■ 

veiy  slight.  Above  tlie  knee  ]30wer  was  retained  in  tlie  reverse  order 
from  the  proximal  to  the  distal  jDortion  of  the  thigh,  the  hip  and  pelvis 
movements  being  mnch  better  preserved  than  those  at  the  knee. 

A  stndy  was  made  of  the  power  of  pantomime,  both  with  the  para- 
Ij^zed  and  nnparalyzed  limbs.  With  the  latter  pantomime  was  entirely 
j)reserved  for  all  practical  purposes,  snch  as  beckoning,  signing  away, 
pointing  to  attract  attention,  emphasizing  his  meaning,  etc.  He  could 
also  use  his  badly  paralyzed  arm  to  a  considerable  extent  for  expressi^-e 
purposes.  On  asking  him  to  indicate  his  age  with  this  arm,  he  did  so 
by  striking  with  the  paralyzed  hand  on  his  knee  seven  times,  hfting  the 
limb  chiefly  with  trunk  muscles,  showing  thereby  that  he  meant  his  fin- 
gers multipled  by  seven,  -namely,  thirtj^-five  years.  He  was  capable  of 
transferring  an  idea  into  his  paralyzed  limb  and  making  use  of  it,  al- 
though very  imperfectly,  to  communicate  with  others.  He  could  use  the 
paralyzed  member  just  as  far  as  its  loss  of  motor  power  would  permit. 


Might-sided  Pseiidoiulbar  Paralysis  and  OpMJialmoplegia — Anarthria — 
MarJced  OroUngual  Paresis — Full  Preservation  of  Pantomime,  hit  Con- 
sideraNe  Mental  Apathy. 

J.  K.,  aged  thirty-five,  white,  clerk,  was  admitted  to  the  Philadelphia 
Hospital  in  October,  1887.  He  had  a  history  of  sj'philis.  Right-sided 
paralysis  with  speech  disturbances  came  on  suddenly  just  before  admis- 
sion ;  December,  1888,  he  had  a  second  slight  apoplectic  attack. 

He  wrinkled  his  forehead  and  closed  both  eyes  firmly,  but  di'ew  up 
the  angle  of  his  mouth  better  to  the  left  than  to  the  right.  In  attempt- 
ing to  whistle,  the  left  halves  of  the  lips  contracted  and  puckered,  but 
the  right  half  of  the  upper  lip  remained  perfectly  flat.  The  right  upper 
extremity  was  strongly  contractured  at  the  shoulder  and  elbow,  so  that 
the  arm  was  drawn  with  gi'eat  force  to  the  side,  and  carried  with  the 
hand  spread  out  across  the  chest.  Loss  of  power  and  contractures  were 
the  greatest  from  above  downward — from  shoulder  to  finger-tips.  He 
had  more  power  over  the  distal  than  over  the  proximal  movements. 
Strong  contractm-e  was  present  at  the  knee  and  some  at  the  hip,  but  he 
had  slight  use  of  the  quadriceps  and  some  abihty  to  flex  with  the  muscles 
of  the  thigh.  Ankle  and  foot  showed  no  contracture.  He  had  diminished 
control  over  the  movements  of  the  foot  and  toes,  proT)ably  the  less  power- 
over  abduction  and  extension.  The  general  conclusion  as  to  the  lower 
extremity  was  that  paralysis  was  comparatively  complete,  and  nearly 
equal  for  proximal  and  distal  portions,  but  jDrobably  greater  in  the 
proximal.  Knee-jerk  was  increased  on  the  right,  but  no  ankle-clonus 
was  present.     Sensation  was  unaffected. 

G.  E.  de  Schweinitz,  ophthalmologist  to  the  hospital,  reported  as  fol- 
lows :  vision  about  one  fifth  of  normal ;  pupils  unequal — right,  non-re- 
sponsive to  light ;  left  responds  to  light  and  shade.  Oculomotor  palsy 
of  the  right  side,  with  limitations  of  the  movements  of  all  the  muscles 
except  those  supplied  by  the  fourth  and  sixth  pairs ;  also  slight  ptosis ;  in 
the  left  eye  divergent  squint  and  inward  limitations ;  the  excursion  of 
the  eye  in  the  other  directions  was  about  normal.  Oval  disks  distinctly 
atrophic.  Marked  eccentric  narrowing  of  the  fields  of  vision,  the  tem- 
poral fields  being  correspondingly  narrower,  but  no  true  hemianopsia. 


ArilJJSIA   AM)    OTUEli  AFFECTIONS   OF  SVEECU.  21)1 

This  man's  speech  trouble  was  distinctly  an  anai-thria.  He  under- 
stood everything-  that  was  said  to  him ;  he  was  neither  mind-blind  nor 
word-blind.  He  eould  speak  voluntarily;  evidently  rehearsed  phrases 
and  sentences  j)roi)erly  in  his  mind ;  and,  indeed,  lie  formed  and  uttered 
words  correctly,  althoujj^h  he  sometimes  mispronounced  them.  His  de- 
fect of  speech  was  clearly  due  to  deficiency  in  plKuiatinw,  articulating, 
and  enunciating'.  He  spoke  with  closed  mouth  and  feeble  movements 
of  the  tongue  and  li})S  ;  liis  speech  was  low  and  muffled — it  was  wanting 
in  force,  tone,  and  emphasis.  Pantomime  was  practically  unaffected  so 
far  as  his  left  liml)S  and  his  head,  face,  and  trunk  were  concerned. 

Marked  differences  in  the  disorders  of  pantomime  will  be  found  in 
•eases  of  paralysis  and  of  motor  and  mixed  aphasia  which  are  apparently 
identical,  or  at  least  very  similar,  in  character,  which  identity  or  close 
similarity,  however,  will  often  be  found  to  be  apparent  rather  than  real ; 
for  investigations  will  show  in  many  cases  differences  in  degree  and  char- 
acter of  the  motor  paratysis,  sensory  symptoms,  and  aphasia,  which  are 
sufficient  to  separate  the  pantomimic  disorders  into  classes. 

The  medico-legal  investigator,  even  without  any  appreciation  of  the 
nature,  extent,  and  location  of  the  lesions,  would  recognize  important  dif- 
ferences between  these  patients — differences  both  in  speech  and  panto- 
mime, which  make  it  essential  for  just  decisions  to  carefully  study  both. 

The  "yes"  and  "no"  of  an  apliasic  are  well  known  to  have  very 
diverse  degrees  of  value.  One  of  these  two  words  may  be  used  to  ex- 
press both  assent  and  dissent,  or  with  its  proper  meaning ;  or  to  express 
assent  when  dissent  is  meant,  or  simply  as  an  emotional,  inter jectional, 
or  accidental  expression.  In  like  manner,  tlie  usual  pantomimic  method 
of  expressing  assent  by  the  forward  nod  or  bowing  of  the  head,  and  of 
indicating  dissent  by  shakes  or  half -rotations  of  the  head,  or  any  other 
movements  apparently  meaning  "  yes"  or  "  no,"  will  be  found  in  aphasics 
to  have  as  many  interpretations  as  the  articulated  "  yes  "  or  "  no." 

The  certainty  and  uniformity  witli  whicli  an  aphasic  expresses  even 
simple  assent  and  dissent  by  word  or  gestm-e,  when  questioned  with,  ref- 
-erence  to  his  wishes  or  with  reference  to  facts,  must  be  taken  into  full 
-consideration.  Some  cases  of  aphasia,  Avhich  were  certainly  not  word- 
deaf,  or  only  partially  so,  were  carefully  tested  at  the  Philadeli)liia  Hos- 
pital with  reference  to  their  ability  to  certainly  and  consistently  exhibit 
assent  or  dissent  to  questions  relating  to  matters  easy  of  comprehen- 
sion. The  results  were  variable,  and  sometimes  contradictory,  puzzling, 
or  amusing.  One  patient,  whose  only  vocabulary  was  the  word  "  no," 
evidently  used  this  word  to  express  both  assent  and  dissent,  but  accom- 
panied its  use  with  such  an  appearance  of  countenance  and  such  gesticu- 
lation as  to  make  it  impossible  to  decide  as  to  her  real  intention.  Some- 
times she  seemed  to  instantly  and  clearly  comprehend  what  was  asked, 
and  showed  this  by  her  countenance,  but  oftener  her  look  was  one  of 
annoyance,  confusion,  or  impatience,  rather  than  of  either  assent  or  dis- 
sent. Another  patient  seemed  to  understand  most  of  what  was  said  to 
her,  particularly  at  first,  but  after  a  few  queries  she  became  emotional, 
•excited,  confused,  and  decidedly  impatient  of  investigation.  A  third, 
whose  accompanying  paralysis  was  less  complete  than  that  of  the  other 
two,  but  whose  vocabulary  was  chiefly  confined  to  the  word  "  no,"  as- 
sented or  dissented  by  means  of  facial  expression,  nodding  her  head,  and 


292  ^   SYSTEM  OF  LEGAL  MEDICINE. 

pantomime  of  fail*  correctness,  and  yet  on  continuing  tlie  examination 
frequently  made  foolish  and  absurd  assents  and  dissents.  A  fourth 
patient  possessed  expressive  gestui-e  and  pantomime  in  a  much  higher 
degree.  She  not  only  understood  all  that  was  said  to  her,  but,  within 
the  limits  of  her  original  capacity,  education,  and  experience,  could, 
so  far  as  her  unparatyzed  members  would  permit,  express  her  mean- 
ing clearly  and  distinctly  by  the  most  significant  pantomime.  With  the 
instruments  which  natui'e  had  left  unimpaired  she  could  promptly  indi- 
cate what  she  wished  to  conve}^,  and  yet  she  was  tremendously  crippled 
so  far  as  ordinary  speech  was  concerned,  and  had  as'  a  most  common 
method  of  vocal  repty  a  routine,  recurring  utterance,  ''  come-on-to-nong.'^ 
Her  pantomime  had  high  propositional  value.  In  studjdng  her  panto- 
mimic powers,  for  instance,  I  asked  her  age,  and  with  her  unparalj^zed 
left  hand  she  opened  and  shut  it  fourteen  times,  the  movement  becom- 
ing a  little  slower  and  more  emphatic  as  she  approached  the  end.  She 
told  us  in  this  that  she  was  seventy  years  old ;  and  when  I  said  to  her, 
"You  mean  you  are  seventy  years  oldf"  she  nodded  her  head  "yes"  in 
a  most  emphatic  manner.  I  asked  her  how  long  she  had  been  sick,  and 
with  her  hand  she  promptly  told  me  fifteen  years.  I  said  to  her,  "  You 
mean  twenty."  She  shook  her  head  "  no,"  and  again  opened  and  shut  her 
hand  three  times  to  indicate  fifteen. 

Great  care  should  be  taken  not  to  misinterpret  the  emotional  mani- 
festations of  an  aphasic.  The  gestures  and  appearances  of  the  face 
indicative  of  displeasure,  anger,  obstinacj^,  iiTitability,  etc.,  are  often 
strongly  suggestive  of  dissent ;  while,  on  the  other  hand,  those  which 
merely  indicate  pleasure,  amusement,  or  playfulness  may  sometimes  be 
mistaken  for  assent  or  accord — facts  which  the  last  two  cases  particu- 
larly illustrate. 

True  amimia  is  an  intellectual  disorder  just  as  is  true  speechlessness. 
It  may  be  correct  to  say  that  emotional  language  is  apparently  unaffected 
in  aphasics,  but  it  would  not  be  correct  to  say  that  it  is  entii'ely  unaf- 
fected. The  expression  of  the  emotions,  while  frequently  correct,  some- 
times energetic,  and  often  violent,  is  in  serious  cases  of  distiu'bauce  of 
intellectual  pantomime  not  uniform  and  under  control.  In  many  nor- 
mal individuals  emotional  manifestations  maj  be  instantly  controlled  at 
an}^  stage ;  and,  in  accordance  with  varying  inhibitor}^  ]30wers  in  differ- 
ent individuals,  weeping  can  be  turned  to  laughing,  a  smile  to  a  frown, 
the  sounds  of  lamentation  to  those  of  rejoicing,  by  the  trained  and  skill- 
ful actor,  and  in  varying  degree  this  power  of  control  is  preserved  in  all 
normal  individuals.  In  aphasics  with  serious  disturbances  of  pantomime, 
the  losses,  when  in  the  emotional  side,  are  seen  in  meaningless  continua- 
tions or  repetitions,  slow  transitions,  and  in  undue  excitement. 

The  following  are  the  notes  in  detail  of  two  of  the  nine  cases  sum- 
marized above  (p.  30) : 

Right  Hemiplegia — Nearhi  Complete  Aphasia  Chiefly  of  Motor  Type — 
Varying  Conditions  of  Pantomime. 

R.  E.,  aged  fifty-four,  white,  has  been  in  the  wards  and  out-wards  of 
the  Philadelphia  Hosj^ital  most  of  the  time  for  twenty  years,  having  first 
entered  the  institution  because  of  an  attack  of  apoplexy  which  occurred 
during  labor  and  left  her  aphasic  and  paralyzed  on  the  left  side.     She 


Al'IlA,'ilA   jyi)    OTIIEU   AITECTIOXS   OF  SPEECH.  293 

soon,  liowevi'T,  hccaine  able  to  walk.  Xiue  or  ten  years  after  tlie  first 
attack  she  had  a  fit,  and  about  three  years  ago  she  i)robaV)ly  had  a  sec- 
ond apopleetie  attack  or  seizure,  falling  in  the  <^)nt-wards  of  the  hospital. 
Since  this  fall  slie  had  complained  of  much  pain  in  the  right  thigh  and 
had  not  been  able  to  walk. 

This  patient  showed  a  curious  confusion  both  of  si)eech  and  panto- 
mime. !She  apparently  imderstood  all  or  almost  all  that  was  said  to  her, 
but  seemed  to  take  in  what  was  said  with  great  slowness.  She  conveyed 
the  impression  of  one  who  required  a  sharp  and  strong  mental  stimulus 
to  whip  her  cerebral  centers  into  activity.  She  assented  by  "yes"  and 
dissented  by  "  no,"  and  of  tener  than  not  correctly ;  nevertheless  her  "  yes  '^ 
and  "  no  "  could  not  l)y  any  means  be  relied  on — she  evidently  used  some- 
times one  for  the  other,  and  presented  a  difference  from  the  last  patient 
in  never  correcting  herself,  "\^^lile  apparently  answei'ing  propei'ly  to 
some  easily  understood  query,  in  other  cases  her  assent  or  dissent  by 
speech  was  foolish  or  absurd.  When,  asked,  for  example,  if  her  name 
was  Smith  she  answered  '•  j^es ;"  Bro's^^l '?  "  Yes ;"  Jones '?  "  Yes,"  etc.  She 
could  not  or  would  not  repeat  anything  from  dictation. 

Her  pantomime  was  much  aif ected,  and,  like  her  speech,  of  a  confusing 
variety.  Frequently,  for  instance,  she  used  the  forwaixl  nod  for  assent 
appropriately,  and  similarly  the  side  wise  shake  or  rotation  of  the  head 
for  "  no."  Now  and  then,  however,  she  evidently  nodded  "  yes  "  when  she 
meant  "  no  "  ;  and  this  pantomime,  like  her  speech,  was  never  correct  spon- 
taneously. She  never  used  or  could  be  induced  to  use  lier  unparalyzed 
hand  and  arm  to  enforce  anything  she  said.  In  attempting  conversations 
with  her  she  usually  made  good  use  of  her  face  for  emotional  expression ; 
smiling  when  pleased,  frowning  when  angered  or  displeased,  etc. 

To  the  little  speech  and  pantomime  this  patient  had,  the  word  ''  uni-e- 
liability  "  was  particularly  applicable. 

EUjM  Hemiplen'ia  With  Marled  Contractures — Complete  Aphasia  of  the 
Mixed  Type — A  Single  Recurring  Utterance — Almost  Complete  Amimia. 

J.  E.,  aged  foi-ty,  had  had  two  paralytic  attacks.  The  fii'st  had  caused 
moderate  loss  of  power  in  the  arm,  leg,  and  face,  greatest  in  the  arm, 
and  so  far  as  could  be  learned  had  not  left  her  with  any  aphasia.  A  f cav 
months  later,  three  years  before  the  examiiuition  here  detailed  was  made, 
she  had  a  second  and  more  severe  apoplectic  seizure,  which  caused  pro- 
found right-sided  paralysis  and  aphasia.  The  right  lower  extremity  was 
entii'ely  helpless  and  showed  some  permanent  flexure  at  the  knee,  the  toes 
extended  and  the  foot  slightly  flexed ;  the  right  upper  extremity  was  also 
totally  paralyzed,  the  wrist  and  elbow  in  a  permanent  position  of  slight 
flexure ;  the  fingers  were  extended  and  somewhat  approxunated  to  and 
looped  around  the  middle  finger. 

The  lines  of  the  face  were  not  so  well  marked  on  the  right  as  on  the 
left.  The  tongue  could  be  protruded  and  deviated  to  the  right.  In  voli- 
tioual  movements  of  the  mouth  and  lips — as  in  an  attempt  to  display  the 
teeth — the  face,  or  moi-e  coi-rectlv  the  angle  of  the  mouth,  was  dra^vn  to 
the  left. 

Sensation  was  apparently  unimpaii'ed,  but  the  examination  could  not 
be  thoroughly  made.  The  right  knee-jerk  was  quite  spastic,  but  no  ankle- 
clonus  was  elicited.    A  tap  on  the  right  patellar  tendon  was  followed  by 


294  ^   SYSTEM  OF  LEGAL  MEDICINE, 

visible  and  palpable  contraction  of  the  C[nadriceps  mnscle  and  tendon, 
but,  probably  owing  to  tlie  partial  fixation  of  the  knee-joint,  the  leg  was 
not  propelled.  At  rest  the  toes  of  the  left  foot  could  be  seen  in  regular, 
rather  fine  movement.  The  hj^eru'ritability  of  nerve,  perhaps  also  of 
muscle,  was  also  illustrated  in  the  right  upper  extremities,  "\\1ien  the 
dorsiun  of  the  wi'ist  was  tapj)ed,  a  feeble  but  distinct  clonus  became  ap- 
parent, and  gentle  taps  on  the  other  tendons  or  muscles — triceps,  deltoid, 
biceps,  etc. — caused  contractions. 

Whether  or  not  tliis  woman  was  word-blind  I  could  not  determine 
without  a  knowledge  of  her  previous  history.  She  was  not  word-deaf, 
at  least  not  complete^  so.  She  impressed  me  as  one  of  those  aphasic 
patients  who  having  fu'st  been  word-deaf,  or  largeh'  thus  affected,  had 
graduallj'  regained  some  power  of  understanding  spoken  words.  She 
was  certainly  not  psychically  bHnd.  She  could  close  the  eyes,  protrude 
the  tong-ue,  etc.,  when  these  or  similar  performances  were  gone  through 
before  her ;  she  could  also  protrude  the  tongue  on  command,  close  the 
eyes,  and  lift  up  the  left  hand,  but  scarcely  more  than  this. 

Her  speech  and  pantomime  might  be  said  to  be  summed  up  in  her 
^' la-la"  and  laugh,  and  a  much  less  frequent  expression  of  anger  or  dis- 
jjleasm'e,  which  was  usually  accompanied  b}'  a  movement  of  covering  her 
mouth  with  her  hand.  The  appearance  of  her  face  could  not  be  said  to 
be  without  expression,  but  like  her  recurring  utterance,  it  was  an  appear- 
ance nearly  always  the  same.  It  might  mean  that  she  was  ]3leased,  it 
might  signify  assent  or  dissent,  it  might  mean  nothing  at  all.  Some- 
times the  "  la-la "  and  the  laugh  became  louder  and  more  emphatic,  but 
that  was  aU.  She  never  nodded  the  head  in  the  usual  manner  for  "  jq^  " 
or  for  ''no."  Only  two  differences  could  be  made  out  in  the  study  of 
her  case :  one,  that  her  usual  utterance  and  gTimace  were  at  times  more 
demonstrative  or  even  more  violent  than  at  others ;  the  other  was,  as 
above  stated,  that  she  had  a  look  of  displeasure  accompanied  by  putting 
the  hand  to  the  mouth. 

A  case  of  this  kind  would  rank  in  general  terms  as  one  of  mixed  con- 
cept-motor aphasia.  Using  the  ordinary  terms,  her  loss  of  pantomime 
and  her  loss  of  speech  were  both  amnesic  and  aphasic,  the  former  largely 
predominating.  She  seemed  to  be  totally  unable  to  conceive  or  recall 
either  proj^er  words  or  movements.  The  lesion  was  of  such  a  character 
as  to  have  prohibited  any  education  of  her  right  hemisphere  for  these 
purposes.  It  probably  destroyed  not  only  both  capsules,  but  also  the 
internal  commissures  for  speech. 

The  following  quotation  from  Kussmaul  is  of  interest  in  connection 
with  the  report  of  this  and  the  preceding  ease : 

"  A  woman  was  paralyzed  on  the  left  haK  of  her  body  and  aphasic 
from  apoplexy.  She  still  had  at  her  disposition  only  the  following  little 
phrases,  which  she  uttered  with  interjectional  sj^rightHuess  :  *  Oui,  par- 
bleu  ' '  '  Tiens  ! '  and  '■  Vous  comprenez  !  '  When  asked  if  she  wished  to 
eat,  she  answered,  '  Oui,  parbleu  ! '  ^\'liat  was  her  name  ?  '  Oui,  par- 
bleu  ! '  or  also  *  Tiens  ! '  in  a  mocking,  snappish  tone.  She  seemed  per- 
suaded that  her  answers  Avere  to  the  point.  She  often  added,  'Vous 
comprenez  ! '  in  a  tone  in  which  a  person  would  use  it  who  thinks  he  has 
convinced  the  person  speaking  \nX\\  him.  She  often  made  use  of  gest- 
ures, which  were  as  useless  and  limited  as  her  discourse  petered  out.  Here 
were  amnesic  or  combined  amnesic  and  ataxic  derangements." 


Al'IIASlA    AMJ    OTUEli   AFl'lCCTIOXS    OF  iU'EECU.  295 

I  append  notes  of  an  interesting  case  kindly  furnished  me  by  the  late 
Dr.  J.  A,  Jeffries,  of  Boston  : 

Motor  Apluma — Onltj  Affirmative  and  Negative  Pantomime — Sometimes 
Confused  Contraction  of  Visual  Fields. 

The  patient,  a  woman  fifty-five  j'ears  okl,  married,  first  came  nnder 
observation  Jidy  7,  1891,  with  a  report  that  she  had  been  struck  dumb. 
Her  liistory,  as  gathered  from  her  sister,  and  later  from  herself,  was  as 
follows :  On  the  afternoon  of  the  4tli  of  July,  while  celebratuig  with 
some  friends,  she  tripped  on  a  rocking-chair  and  fell  to  the  ground.  She 
was  not  stunned,  got  up  l)y  herself,  and  continued  about  the  room  for  fif- 
teen minutes ;  then  feeling  sleepy,  she  lay  down  on  a  bed  and  went  to 
.sleep  for  two  hours.  On  waking  slu^  rejoined  the  company  and  began 
to  speak,  l)ut  stopped  short  in  the  middle  of  a  sentence,  unable  to  say  a 
word.  She  had  no  pain,  vertigo,  or  other  symptoms.  She  had  never 
been  pregnant. 

She  was  a  strong,  straight,  healthy-looking  woman  with  an  intelli- 
gent cast  of  coiintenance.  Examination  of  heart,  lungs,  and  abdominal 
•organs  was  negative.  Urine  1017,  acid,  free  from  alljumin,  sugar,  bile, 
and  abnormal  sediment.  No  atheroma.  A  large  black-and-blue  spot 
was  present  about  the  left  eye,  extending  into  the  temple.  Her  eyes 
moved  freely  in  all  directions,  either  open  or  with  one  covered  ;  no  dip- 
lopia ;  pupils  of  normal  size,  resj)onded  promptly  to  the  light,  to  near 
vision,  and  on  irritation  of  the  skin.  No  ptosis  of  the  right  eye ;  the 
left  lid  drooped,  l)ut  was  much  swollen.  No  difference  between  the  two 
sides  of  the  face  in  mimetic  movements  or  in  expression  of  emotion. 
Tongue  extended  straight ;  could  be  moved  freely  and  rapidlj'  in  every 
direction,  and  rested  symmetrically  in  the  mouth.  Fauces  symmetrical ; 
no  difficulty  in  swallowing.  Vocal  cords  moved  well  in  respiration  and 
in  laughing ;  sneezed  with  explosion.  No  i3aresis  of  neck  or  of  body  or 
legs. 

Right  arm  not  so  strong  as  the  left,  but  both  were  fairly  strong  and 
freely  moved.  Tendon  reflexes  normal,  the  same  on  both  sides.  There 
was  possibly  some  blunting  of  the  sense  of  contact  in  the  right  arm  and 
face,  but  the  faintest  touch  was  perceived  the  same  as  on  the  left  side. 

Speech  was  al)sent.  On  effort  to  speak  there  were  a  few  slight  motions 
■of  the  tongue  and  lips,  and  at  times  a  slight  inarticulate  sound.  The 
vowel  sounds  were  more  pi'ouounced,  a  and  e  l)eing  recognizable.  Could 
not  repeat  or  read  aloud ;  could  not  write  alone  from  dictation  or  co})y — 
in  all  efforts  to  do  so  the  hand  was  very  clumsy.  She  could,  however, 
draw  at  request  a  dog,  house,  man,  or  the  like,  much  after  the  style  of 
the  old  Indian  inscriptions.  She  could  not  read.  She  apparently  under- 
stood perfectly,  doing  as  she  was  directed,  laughing  at  a  pun.  Her  only 
method  of  conveying  ideas  seemed  to  be  by  nodding  or  slinking  the  head. 
She  used  no  other  form  of  pantomime.  When  asked  a  cpiestion  she 
.iissented  or  dissented  ^vith  the  head,  l)ut  fi-equently  after  a  nod  would 
'<!ontradict  or  correct  herself  by  a  violent  shake,  so  that  after  each  ques- 
ition  I  was  ol)liged  to  wait  for  what  might  come  after.  Objects  were 
recognized  pro])erly,  and  her  ol^servation  was  good.  There  was  no  deaf- 
ness. The  patient  was  formerly  an  habitual  reader  of  the  papers,  and 
•occasionally  wvote  a  letter. 


296  A  SYSTEM  OF  LEGAL  MEDICINE. 

Tliere  were  no  signs  of  alopecia,  no  scabs  in  the  month,  or  on  the  skin^ 
no  enlarged  lymphatics,  and  the  tibial  and  other  long  bones  were  smooth. 

In  the  coiu'se  of  the  next  two  weeks  there  was  considerable  improve- 
ment in  the  power  of  speech.  The  power  of  repeating  fii-st  retm-ned  little 
by  little,  and  by  the  time  she  conld  repeat  sight- words,  "  yes  "  and  "  no  "- 
returned.  She  conld  sign  her  name,  ^viite  a  few  letters  from  copy,  but 
conld  not  complete  "  Boston "  or  wi-ite  offhand.  At  this  time  I  found 
■  her  visual  field  reduced  to  about  thirteen  degrees  all  the  way  round  in 
both  eyes,  and  that  she  had  lost  all  arithmetical  power.  As  the  power 
of  speech  came  back  the  paresis  of  the  lips  became  apparent.  These  in 
speaking  moved  slowly  and  clumsily,  as  if  cold,  while  in  other  motions 
they  were  steady  and  oifered  nothing  peculiar. 

By  the  end  of  August  the  patient  had  made  material  progress  and 
was  if  anything  better  than  when  last  seen  in  December.  The  grip  of 
the  right  hand  was  one  hundi*ed,  of  the  left  eighty-four ;  there  was  but 
the  barest  trace  of  the  former  immobility  of  the  lips  during  speech.  This 
was  quite  free  and  spontaneous,  the  vocabulary  good,  and  the  use  of  the 
words  good.  At  times  she  would  hesitate  for  a  word,  but  would  not  use 
a  wi'ong  one.  There  was,  however,  a  period,  when  sj^eech  was  fii^st  retmni- 
ing,  when  ^vl'ong  words  were  used  frequently,  but  corrected.  The  power 
of  reading  was  very  limited ;  at  times  she  could  get  through  a  few  hues 
correctly,  but  as  a  rule  she  "  forgot  what  the  tii-st  part  of  the  word  was 
before  she  got  to  the  end." 

Writing  was  confined  to  her  name.  All  forms  of  testing  gave  nega- 
tive results.  Hearing  was  normal,  also  the  power  to  understand  words. 
The  power  to  count  and  do  simple  sums  was  very  imperfect.  She  could 
count  out  loud  correctly,  but  if  given  a  few  piles  of  matches,  she  would 
mf.ke  some  wrong  counts,  seven  for  eight,  or  the  like.  She  could  not 
make  change,  but  could  name  the  coins.  The  visual  field  was  ample, 
and  the  recognition  of  objects  normal.  Lastly,  as  speech  retiu-ned  there 
was  a  time  when  she  filled  out  her  imperfect  language  by  pantomime, 
which  often  enabled  me  to  give  her  the  right  word. 


THE    TRAUMATIC    NEUROSES:    BEINO    A    DESCRIP- 
TION OF   THE   CHRONIC  NERVOUS   DISORDERS 
THAT  FOLLOW   SHOCK  AND   INJURY. 

BY 

CHABLES  L.  DANA,  A.M.,  M.D. 


Synonyms. — Concussion  of  tlie  spine,  railway  spine,  railway  brain^ 
traumatic  neurasthenia,  traumatic  hysteria,  hystero-traumatic  disorders, 
traumatic  hystero-neurasthenia. 

This  article  will  inchide  a  description  of  concussion  and  shock,  but 
not  of  traumatic  insanity,  or  of  the  gi'oss  lesions  of  the  nervous  system 
caused  by  injury. 

Definitions. — As  my  article  may  be  sometimes  referred  to  by  per- 
sons not  familiar  with  all  the  technical  words  used  in  neurological  medi- 
cine, I  propose  to  give  here  brief  definitions  and  descriptions  of  some  of 
the  terms  employed. 

A  neurosis  is  a  morbid  nervous  state,  and  the  word  is  practically  syn- 
onymous with  a  nervous  disease.  When  the  neiu-osis  occurs  withcmt 
any  change  in  the  structure  of  the  nervous  tissues  it  is  called  a  functional 
or  non-organic  neurosis.  Wlien  it  is  due  to  some  structural  change, 
such  as  intiammation  or  softening  of  the  nervous  tissues,  then  it  is  called 
an  organic  neiu'osis. 

Apsycliosis  is  a  morbid  mental  state.  The  diiferent  forms  of  insanity 
are  called  psychoses.  There  may,  however,  be  morbid  mental  states 
which  are  not  true  insanities,  such,  for  example,  as  decided  mental  de- 
pression, a  tendency  to  tixed  ideas,  and  hypoehrondriacal  states.  Hys- 
teria is  sometimes  classed  under  the  head  of  the  j)sychoses. 

Slioclx  is  a  sudden  depression  of  the  vital  functions,  especially  of  the 
circulation,  due  to  the  nervous  exhaustion  following  an  injm-y  or  a  sud- 
den violent  emotion,  and  resulting  either  in  immediate  death  or  in  pro- 
longed prostration.  (Foster.)  Shock  is  spoken  of  as  being  either  coi-po- 
real  or  i:)sycliic.  Corporeal  shock  is  that  form  in  which  the  depression 
of  the  vital  powers  is  produced  by  a  violent  injury  or  a  sudden  loss  of 
blood.  Psychic  shock  is  that  form  in  which  the  depression  is  produced 
by  an  emotion.  Often  shock  involves  l)oth  these  elements.  So  far  as 
I  can  learn  there  is  no  way  by  wliich  the  two  conditions  can  be  distin- 
guished, apart  from  the  history  of  the  case ;  in  other  words,  a  severe 
bodily  injury  and  a  \dolent  depressing  emotion  may  produce  exactly  the 
same  nervous  results. 

Concussion  is  a  word  wliich  has  been  much  twisted  out  of  its  original 

297 


298  A   SYSTEM  OF  LEGAL  MEDLCINE. 

meaning.  Properly  speaking,  tlie  term  should  be  applied  only  to  the  act 
itself  in  wbicli  the  body  receives  a  severe  jar.  Practically,  concussion 
means  almost  always  concussion  of  the  brain. 

Concussion  of  the  'brain  is  a  jarring  of  the  brain  substance  without 
laceration  of  its  tissue,  or  with  only  microscopic  laceration.  (Foster.) 
It  is  characterized  by  partial  or  complete  loss  of  consciousness,  with 
feebleness  of  pulse,  coldness  of  the  extremities,  pallor,  and  dilatation  of 
the  pupils,  followed  by  vomiting,  moaning,  restlessness,  jactitation,  and 
somnolence,  mth  warmth  of  the  skin,  a  full,  relaxed  pulse,  and  sometimes 
ii-regular  contraction  of  the  pupUs.  The  state  which  follows  directly 
upon  concussion,  and  which  has  just  been  described,  is  spoken  of  as  col- 
lapse. The  after-effects  of  concussion  of  the  brain  have  been  described 
by  earlier  writers  under  the  name  of  railway  spine,  or  spinal  concussion. 
This,  however,  as  we  shall  show,  is  a  misuse  of  the  term,  and  the  word 
should  only  be  applied  to  the  condition  I  have  described. 

Concussion  of  the  spinal  cord  is  a  condition  which,  in  my  opinion,  prac- 
tically never  occurs.  As  the  term  was  formerly  used,  however,  it  meant 
a  condition  of  the  spinal  cord  produced  by  a  violent  shock,  such  as  that 
which  would  result  by  falling  from  a  height,  by  a  severe  blow  on  the 
back,  or  by  a  railway  collision  or  similar  accident.  A  condition  of  more 
or  less  collapse  with  partial  suspension  or  jierversion  of  the  function  of 
the  s]3inal  cord  was  believed  to  follow  such  accidents.  It  is  the  present 
opinion,  however,  that  these  conditions  are  due  to  concussion  of  the  brain 
and  nervous  shock,  together  with,  in  some  cases,  lacerations  of  ligaments 
and  perhaps  structural  injury  of  the  spinal  cord. 

Neurasthenia  is  the  term  used  to  indicate  a  condition  of  nervous  ex- 
haustion or  nervous  weakness  with  irritability. 

Trauma  means,  strictly  speaking,  a  wound.  The  term  is  used  gener- 
ally as  synonymous  with  an  injury. 

Keuralgia  means  pain  in  the  course  of  nerves. 

Paralysis  is  the  term  used  to  indicate  a  loss  of  power  of  miiscular 
movement.  When  the  paralysis  is  incomplete  it  is  called  paresis  ;  paral- 
ysis affecting  one  half  of  the  bodj^  is  called  hemiplegia  ;  when  it  affects 
the  two  lower  extremities  it  is  caUed  paraplegia  ;  and  when  it  affects  only 
one  limb  it  is  called  monoplegia. 

Ancesthesia  means  a  loss  of  the  sense  of  feeling.  When  there  is  a  loss 
of  the  feeling  of  touch  it  is  called  tactile  anaesthesia,  and  when  there  is 
a  loss  of  sensation  of  pain  it  is  called  pain  anaesthesia,  or  analgesia. 

Tremor  is  the  name  given  to  the  condition  in  which  there  is  a  vibra- 
tory motion  of  the  extremities  or  of  the  muscles  of  the  body.  It  is  due 
to  an  alternate  contraction  and  relaxation  of  muscular  fibers.  These 
contractions  are  rhythmical,  and'  occur  at  a  rate  of  from  three  to  twelve 
per  second. 

History. — It  has  been  knoAvn  since  the  beginnings  of  medicine  that 
injuries  would  cause  different  forms  of  insanity,  and  would  give  rise  to 
epilepsy  and  St.  Vitus's  dance,  and  would  excite  hysterical  attacks.  The 
facts  with  regard  to  what  is  known  as  concussion  of  the  brain  have  also 
been  long  familiar  to  surgical  writers.  In  the  early  jiart  of  this  century 
the  French  and  English  surgeons  reported  and  studied  cases  of  what 
they  termed  "  concussion  of  the  spine."  Their  views  at  this  time  were 
that  as  the  result  of  blows  upon  the  body,  and  particularly  upon  the 
back,  or  as  the  result  of  faUs  or  other  forms  of  injury,  the  functions  of 


THE   TRAUMA  TIC  NEUROSES.  20{> 

the  spinal  cord  mig-ht  be  temporarily  perverted  or  suspended,  causing- 
l)ains,  paralysis,  and  other  symptoms.  The  theory  was  that  the  action 
of  a  severe  injury  or  concussion  upon  the  sjdne  was  analog-ous  to  that 
of  a  blow  upon  the  head:  just  as  the  latter  injury  would  produce  con- 
(•ussion  and  a  sus2:)ension  of  (;ereljral  function,  so  it  was  thought  a  l)low 
up(ni  the  spine  AV'ould  cause  a  functional  disorder  of  the  spinal  cord. 
These  views  were  based  largel}^  upon  histories  of  cases  in  which  after  a 
severe  injury  paraplegia  ensued,  which  paraplegia  in  the  course  of  a  few 
weeks  or  months  entii-ely  disappeared.  Cases  illustrating  this  view  were 
reported  l)y  Boyer  (2),*  Bell  (o),  Sir  Astley  Cooper  (6),  Abercrombie  (8), 
Mayo  (9),  Ollivier  (10),  and  Lidell  (11).  The  earlier  writers  also  studied 
the  effects  of  injuries  in  the  i)roduction  of  chronic  nervous  disorders  due 
to  actual  iujury  to  the  cord  or  brain,  particularly  the  former,  and  cases 
of  traumatic  myelitis  and  traumatic  meningitis  were  put  in  e^ddence. 
Maty  (1),  Clirard  (4),  and  Lidell  (11)  were  among  those  who  contributed 
to  this  phase  of  the  subject. 

In  1818  and  1837  Sir  Benjamin  Brodie  (5)  called  attention  to  certain 
hysterical  affections,  particularly  those  of  the  joints,  following  injury. 
We  find  in  the  writings  of  Girard  (4),  Peronne  (12),  Weir  Mitchell  (14), 
and  Lockhart  Clarke  (15)  contributions  to  the  subject  of  injuries  of  the 
nerves  and  to  the  development  of  organic  disease  of  the  central  nervous 
system  after  injury.  We  find  much  also  in  these  earlier  writers  upon 
the  general  subjects  of  concussion  and  shock.  It  was  not,  however, 
until  the  appearance  of  Erichsen's  book  (13)  in  1866  that  the  study  of  the 
functional  nervous  affections  following  injury  was  reall}'  begim,  and  all 
credit  must  be  paid  to  this  observant  surgeon  for  the  epoch-making  work 
which  he  did  at  this  time.  Erichsen's  teaching  was  that  injuries  would 
produce  at  times  an  actual  concussion  of  the  spine,  in  the  sense  that  it 
temporarily  suspended  the  functions  of  that  organ  and  perhaps  for  some 
time  disturbed  its  normal  workings.  He  also  taught  that  injuries  which 
did  not  actually  fracture  the  spine  or  produce  gross  lesions  of  the  cord 
and  membranes  would  lead  to  various  grades  of  chronic  spinal  menin- 
gitis, and  finally  he  taught  that  following  these  injuries  there  sometmies 
developed  peculiar  chronic  nervous  disorders,  to  which  he  gave  the  name 
''  concussion  of  the  spine,"  or  railway  spine.  These  disorders  he  consid- 
ered to  be  due  sometimes  to  spinal  anaemia,  sometimes  to  spinal  hyper- 
£emia,  and  at  other  times  to  meningitis.  The  authority  of  Erichsen's 
teachings  remained  but  little  questioned  for  a  good  many  years.  Vari- 
ous further  contril>utions  to  this  subject  were  made  by  Buzzard  (16), 
Fletcher  (17),  Webber  (21),  and  others.  In  systematic  treatises  such  as 
those  of  Erl)  (29)  and  Leyden  (26,  31)  "  spinal  concussion"  was  discussed 
as  though  it  were  a  recoguized  clinical  entity. 

In  1878  Charcot,  reviving  the  observations  of  Brodie,  called  attention 
to  the  fact  that  traumatisms  sometimes  develop  local  hvstei'ical  i^henom- 
ena.  Esmarch  (1872),  Shaffer  (1880),  Ketch  (1887),  MitcheU  (188."))  have 
also  contributed  to  this  same  subject.  A  good  many  German  and  a  few 
French  wiiters  meanwhile  reported  various  cases  of  concussion  of  the 
spine,  and  most  of  them  accepted  more  or  less  fully  the  views  enun- 
ciated by  Erichseu. 

*  The  si^eeial  ai'tieles  by  these  wi-iters  will  be  found  an*anged  chronologically  imder 
the  bibliography  at  the  end  of  this  article. 


300  A   SYSTEM  OF  LEGAL  MEDLCLNE. 

In  1882  a  new  stimulus  was  given  by  Mr.  Herbert  W.  Page,  who  pub- 
lished a  work  entitled  Injuries  of  the  Spine  and  Spinal  Cord  (51),  in  which 
he  sharply  criticised  the  views  taken  by  Erichsen.  He  denied  the  exist- 
ence of  spinal  concussion,  and  showed  that  many  of  the  cases  of  supposed 
railway  S23ine  were  nothing  but  cases  of  a  temporary  nervous  distui-b- 
ance,  or  of  hysteria  or  simulation.  Shortly  before  this,  Dr.  R.  M.  Hodges 
(47)  had  published  a  series  of  cases  in  which  he  also  disputed  the  seri- 
ous character  of  the  so-called  concussion  symptoms.  From  this  time  on, 
the  critical  study  of  the  traumatic  neuroses  may  be  said  to  have  begun. 
Contributions  bearing  uj^on  it  poui'ed  in  with  great  rapidit}^  from  Ger- 
man,  French,  and  American  observers.  In  this  country  Drs.  G.  L.  Wal- 
ton (55),  J.  J.  Putnam  (60),  Hamilton  (57),  Dana  (61),  Johnson  (66),  Knapp 
(117),  and  Dercum  wrote  special  articles  upon  the  subject.  To  Drs.  Wal- 
ton and  Putnam  in  particular,  credit  is  due  for  showing  that  some  of 
the  cases  that  have  been  known  as  railway  spine  were  cases  of  major 
hysteria.  In  France,  Charcot  (1887)  (89)  and  his  puj)ils,  Berbez  (124), 
Terrillon  (68),  and  Cuinon  (125),  studied  the  phenomena  of  traumatic 
hysteria,  and  showed  that,  in  that  country  at  least,  trauma  was  especially 
apt  to  lead  to  hysterical  disorders.  In  Germany  active  interest  in  the 
subject  of  the  traumatic  neuroses  may  be  said  to  have  begun  in  1884, 
when  a  series  of  articles  was  published  by  Thomsen  and  Oppenheim, 
and  later  by  Oppenheim  (74)  alone.  The  teaching  of  Oppenheim  was 
that  as  a  result  of  injuries  there  developed  a  series  of  chronic  nervous 
symptoms  which  had  a  rather  definite  character,  so  much  so  that  the 
special  name  of  "  traumatic  neurosis "  might  be  ap23lied  to  it.  Oppen- 
heim's  work  called  out  a  great  many  articles  of  a  controversial  character, 
in  which  it  was  asserted  that  the  element  of  malingering  had  been  very 
much  overlooked  by  the  "v^a-iter  referred  to.  It  was  not  until  about  1888 
that,  through  the  influence  of  French,  American,  and  English  writers, 
the  striking  part  played  by  major  hysteria  was  acknowledged  to  exist  in 
the  traumatic  nervous  disturbances.  Dr.  William  Thorburn  (105),  in  his 
work  entitled  A  Conirihntion  to  tlie  Surgery  of  tlie  8pin(d  Cord,  presented 
the  cpiestion  systematically  and  clearly  to  English  readers. 

This  brings  the  question  down  to  the  present  time.  It  will  be  seen  that 
at  first  the  whole  matter  was  in  the  surgeon's  hands,  and  was  studied 
from  a  surgeon's  standiDoint.  Erichsen,  who  first  suggested  the  nervous 
side  of  the  case,  was  a  surgeon.  So  also  was  the  first  German  writer, 
Rigler.  It  was  not  until  after  the  appearance  of  Page's  book  that  neu- 
rologists took  up  the  matter  seriously.  Then  clinical  and  pathological 
views  experienced  a  rapid  change.  The  conception  of  a  traumatic  hys- 
teria was  soon  worked  out  by  Charcot,  and  that  of  a  traumatic  neuras- 
thenia stiU  earlier  by  others.  The  specific  neurosis  theory  advanced  by 
Oppenheim  never  secured  much  of  a  foothold.  The  advances  being 
made  now  are  largely  in  the  direction  of  closer  clinical  observation 
and  more  exact  methods  of  diagnosis,  and  in  pathologj^  and  pathological 
anatomy. 

Mooted  Points. — The  points  about  which  present  interest  most  cen- 
ters are :  first,  the  question  of  the  existence  or  not  of  true  concussion  of 
the  spinal  cord ;  second,  the  importance  of  the  part  played  by  malinger- 
ing in  the  traumatic  neuroses ;  third,  the  existence  of  a  major  hysteria 
with  anaesthesias  and  paralyses ;  fourth,  the  question  of  the  existence  of 
a  special  class  of  nervous  symptoms  following  an  injury  and  due  entirely 


THE   TRAUMATIC  NEUROSES.  301 

to  it ;  fifth,  the  question  of  the  existence  of  objeetive  signs  in  these  dis- 
orders l)y  which  one  can  test  the  reality  of  the  alleged  nervous  phenom- 
ena; sixth,  the  existence  and  significance  of  local  nervous  ijhenomena, 
such  as  hysterical  joints  and  local  hysterical  symptoms  of  a  spasmodic 
or  paralytic  character. 

Upon  these  various  points  the  amount  of  literature  that  has  accumu- 
lated is  simply  enormous.  I  have  ventured  to  collect  this  and  present 
it  in  connection  with  ni}'  article,  the  matters  being  arranged  fh-st  chron- 
ologically and  next  in  accordance  with  the  different  subjects  discussed. 
In  the  second  arrangement  I  have  not  included  all  the  articles  placed  on 
the  first  list,  because  many  of  them  could  not  be  classified  and  many  were 
simply  reports  of  cases.  A  study  of  this  bibliographical  list  shows  that 
the  total  number  of  articles  and  works  published  is  two  hundred  and 
seventy-eight.  They  have  appeared  from  writers  in  all  pai-ts  of  the  ci\'il- 
ized  world.  Germany  has  been  most  prolific;  after  this  America,  then 
France  and  Great  Britain. 

English,  27;  French,  51;  German,  118;  American,  G4;  Italian,  6 ; 
Scandinavian,  2  ;  Swiss,  3  ;  Belgian,  2 ;  Dutch,  2 ;  Russian,  4 :  total,  278. 

It  is  ob\dously  impossible  that  any  one  man  should  familiarize  him- 
self with  all  these  articles ;  but  I  have  studied  the  more  important  ones, 
and  I  am  led  to  the  conclusion,  from  their  perusal  and  from  my  own 
personal  experience,  that  many  of  the  mooted  questions  above  refeiTcd 
to  are  rapidly  reaching  a  satisfactory  solution.  Among  American  neu- 
rologists of  to-daj''  I  do  not  think  that  there  is  any  great  difference  of 
opinion  regarding  them. 

As  to  the  first  of  the  points,  that  of  the  existence  or  not  of  such  a 
thing  as  concussion  of  the  spine,  I  beheve  that  the  answer  is  practically 
a  negative  one.  It  is  perhaps  not  impossible  that  a  severe  blow,  pro^D- 
erly  directed,  may  cause  a  temporary  paralysis  of  the  spinal  cord  due  to 
simply  the  molecular  vibration  or  concussion ;  but  such  cases  are  so  ex- 
tremely rare  that  for  practical  purposes  they  need  hardly  be  considered, 
and  personally,  despite  the  cases  that  have  been  brought  in  evidence  by 
Drs.  Hunt  and  Gowers,  I  do  not  think  that  there  is  any  instance  which  can 
be  said  beyond  any  doubt  to  illustrate  a  spinal  concussion.  Most  of  the 
cases  that  hav^e  been  called  such  have  been  undoubtedly  cases  of  hemor- 
rhage either  external  to  the  dura  or  internal  to  it,  generally  the  former. 
The  reader  must  bear  in  mind,  however,  that  the  term  "  concussion  of 
the  s})ine  "  is  here  used  in  its  strictly  technical  sense.  Through  the  writ- 
ings of  Erichsen  and  others  immediately  following  him  the  term  was  so 
transposed  as  to  mean  not  strictly  concussion,  but  the  chronic  nervous 
symptoms  following  it,  and  often  in  ordinary  medical  usage  this  meaning 
still  oljtains.  Few  careful  waiters,  however,  now  use  the  term  "  con- 
■cussion  of  the  spine,"  but  in  its  place  employ  the  words  "  traumatic  neu- 
rosis," *'  traumatic  hysteria,"  *'  hystero-traumatism,"  or  some  word  indi- 
cating the  actual  gross  lesion  if  there  is  any,  such  as  "  traumatic  myelitis." 
Sometimes,  after  an  injury,  the  symptoms  of  a  chronic  myelitis  slowly 
develop.  This  is  considered  by  Knapp  a  proof  that  the  spinal  cord  has 
been  "concussed."  It  rather  indicates  that  some  slight  laceration  of  ves- 
sels or  nerve  tissues  occurs,  from  which  reactive  infiammatory  changes, 
gliosis,  or  most  often  sj'philitic  exudates  develop.  One  sees  exact  copies 
of  this  kind  of  traumatic  myelitis  occur  without  trauma. 

With  regard  to  the  second  point,  that  of  the  importance  of  the  element 


302  A   SYSTEM  OF  LEGAL  MEDICINE. 

of  malingering,  tliere  is  perhaps  not  qnite  so  mucli  liarmony  of  opinion. 
This  is  particularly  the  case  among  the  German  writers,  where  a  great 
number  of  articles  upon  the  subject  of  simulation  have  been  written. 
There  has  been,  however,  in  my  opinion,  a  large  personal  element  in  this 
discussion,  and  a  perusal  of  it  leads  me  to  think  that  most  of  the  Ger- 
mans who  have  written  regarding  simiilation  have  not  been  practically 
familiar  with  functional  neui-oses,  such  as  neiu*asthenia,  to  anywhere 
near  the  extent  that  American  neui'ologists  are.  It  would  certainly 
have  been  impossible  for  any  such  lengthy  acrimonious  and  sterile  de- 
bates as  have  occiuTcd  in  Germany  to  have  taken  place  in  America,  and 
in  this  countiy  there  is,  I  feel  assiu-ed,  no  gi^eat  difference  of  oi3inion  as 
to  the  actual  existence  and  the  at  times  serious  nature  of  the  traumatic 
neui"oses.  We  recognize,  of  course,  the  importance,  and  I  mig'ht  add  the 
relative  fi'equency,  of  deceit,  exaggeration,  and  impostiu'e ;  also  the  fact 
that  the  jjrocess  of  litigation  often  aggravates  and  adds  to  the  nervous 
condition.  But  we  do,  I  beheve,  with  great  uniformity  agi-ee  upon  the 
fact  that  functional  nervous  conditions  of  a  chronic  and  sometimes  in- 
tractable character  are  produced  by  trauma. 

With  regard  to  the  tliird  point,  that  of  the  existence  of  a  traumatic 
hysteria,  there  has  been,  I  believe,  no  great  amount  of  controversy.  It 
is  acknowledged  that  the  major  foiins  of  hysteria  as  well  as  the  minor 
fonns  may  follow  ti*auma.  The  investigations  of  late  years  have  been 
more  in  the  line  of  studying  the  frequency,  the  clinical  characteristics, 
and  ultimate  conrse  of  these  disorders.  In  France,  if  we  may  judge 
from  the  medical  literatm-e  of  that  country,  trauma,  when  it  is  followed 
by  any  functional  nervous  disturbance,  is  followed  oftenest  by  hysteria. 
In  this  country  traumatic  hysteria  is  relatively  rarer,  yet  it  is  by  no 
means  veiy  infi*equent. 

With  regard  to  the  fourth  point,  that  of  the  existence  of  a  special 
form  of  functional  neurosis  due  to  injuiy,  viz.,  the  traumatic  neiu'osis, 
agi'eement  has  also  been  reached.  In  the  vast  majority  of  cases  the 
nervous  s^Tuptoms  following  injury,  when  not  due  to  organic  lesion, 
take  the  form  of  a  neurasthenic  condition,  and  this  neurasthenic  condi- 
tion diifers  Ijut  little  from  that  which  is  l^rought  about  by  other  causes. 
Tramnatic  neiu^asthenia  s^anptomatologicall}^  resembles  ordinary  neu- 
rasthenia plus  s}Tnptoms  due  to  local  injuiy,  such  as  sprains,  and  ^-ith 
the  addition  of  a  rather  larger  amount  than  usual  of  pain  in  the  back 
and  tendency  to  exaggeration.  In  very  rare  cases,  however,  there  does 
develop  after  a  time  a  chronic  nervous  disorder,  of  whose  special  char- 
acter I  will  speak  later,  which  has  symptoms  that  are  to  a  certain  extent 
peculiar  to  itself,  though  resembling  multiple  sclerosis.  To  this  rare 
t;^-pe  of  disorder  the  name  of  "  the  grave  traumatic  neiu'osis  "  might  per- 
haps be  given ;  for  the  e^ddence  at  the  present  time  goes  to  show  that  a 
certain  amount  of  incurable  organic  disease  exists  here. 

As  to  the  fifth  point,  the  question  of  the  existence  of  objective  signs 
in  the  traumatic  neuroses,  a  great  deal  has  been  written  and  a  gi-eat  deal 
claimed.  Many  peculiar  symptoms  have  been  elicited  and  a  special  s^Tnp- 
tomatological  value  attriliuted  to  them.  ]\Iy  own  ^dews  upon  their  value 
will  be  stated  in  greater  detail  later.  It  wOl  be  sufficient  to  say  now 
that  we  have  a  sufficient  number  of  objective  tests  to  render  it  impos- 
sible in  almost  aH  cases  for  a  patient  to  deceive  a  skilled  observer. 

As  to  the  sixth  point,  the  existence  of  local  hysterical  disorders,  there 


THE    rn.  I  i  M.  /  TIC  XK  U ROSES. 


303 


has  not  yet  been  very  much  written,  and  the  subject  is  in  a  soni(;\vhat 
misatisfaetory  state.  It  lias  been  shown,  however,  that  arthralgias,  local 
spasms,  paralyses,  and  tremors  may  result  from  injury,  and  that  these 
may  exist  and  be  of  a  purely  functional  character.  The  (juestion  of  the 
amount  and  importance  of  asso(dated  hysterical  or  neurasthenic  stigmata 
lias,  howex'cr,  yet  to  be  woi'ked  out. 

Such,  in  biief,  is  the  history  of  the  rise  and  development  of  our 
knowledge  of  the  functional  nervous  disorders  following  injimes. 

Classification. — It  is  hardly  to  ha  expected  that  perfect  agreement 
can  yet  lie  reached  upon  the  sul)ject  of  classifying  the  functional  nervous 
disorders  that  follow  injury  and  shock.  A  classification  suggested  by 
Dr.  E.  C.  Seguin  in  1889  {Annual  of  the  Universal  Medical  Sciences,  vol.  iii., 
No.  3),  modified  somewhat  in  accordance  with  the  advances  made  since 
that  time,  will  be  used  as  a  guide  here. 


CLASSIFICATION   OF   NERVOUS   DISORDERS   FOLLOWING  INJURY. 


Immediate  Symptoms  : 


f  Shock, 

Transitory  paralysis, 
Delirium,  somnolence,  amnesia, 
Diabetes. 


Late  Symptoms, 

l^liis  (in  many  cases)  physical 
injuries : 


1.  The  Traumatic  Neuroses. 

(ft)  Traumatic  neurasthenia. 
{!))  Traumatic  hysteria, 
(c)  Mixed  and  grave  types. 
((7)  Local  neuroses. 

2.  Organic  Affections. 

(rt)  Myelitis,  meningitis,  etc. 

(Z>)  Degenerative  diseases  of  brain  and  cord :  \dz., 
locomotor  ataxia,  progressive  muscular  atro- 
pliy,  miiltiple  sclerosis,  epilepsy,  paralysis  agi- 
taiis,  ties,  exophthalmic  goiter.   • 

(c)  Lifeetive  neuroses :  chorea,  sj'philis,  tubercu- 
losis. 

(r?)  Tumors. 

3.  Psychoses. 


Out  of  the  above  long  list  I  have  to  discuss  only  the  subjects  of 
shock  and  the  traumatic  neuroses.  It  is  these  which  are  most  common 
aside  from  physical  injury,  and  it  is  these  which  give  rise  to  the  most 
important  kinds  of  litigation.  It  is  extremely  rare  for  other  forms 
of  nervous  troubles  than  the  neuroses  referred  to  to  come  into  court. 
Chorea,  for  example,  though  often  excited  by  fright,  rarely  occurs  in 
adults,  and  is  almost  never  developed  in  connection  ^\'ith  litigation  cases. 
Epileps}',  too,  though  sometimes  the  resnlt  of  injiuy,  occurs  chiefly  before 
maturity,  and  it  is  not  often  that  the  disease  can  be  shown  to  be  due  to 
an  injury  alone. 

SHOCK  AND  CONCUSSION. 

The  nature  of  shock  and  concussion  has  already  been  defined.  Con- 
cussion is  the  physical  jar;  shock  is  the  effect.  Shock  resulting  from 
concussion   is  called  corporeal ;   but  almost  the  same  class  of  symp- 


304  A   SYSTEM  OF  LEGAL  MEDLCINE. 

toros  can  be  produced  l3y  great  emotion,  and  tliis  form  of  shock  is  called 
psycliical. 

When  a  person  receives  a  severe  blow  upon  tlie  head  he  falls  to  the 
ground  partly  or  wholly  unconscious.  His  voluntary  muscles  are  re- 
laxed, and  often  there  is  at  the  same  time  a  paralysis  of  the  sphincters, 
so  that  faeces  and  urine  are  voided.  The  pulse  is  slow,  irregular,  weak, 
and  comj)ressible.  The  reflexes  are  abohshed.  The  respiration  is  shal- 
low and  slow  in  rhythm.  The  extremities  are  cold,  the  face  is  pale,  the 
skin  often  covered  mth  moisture.  If  the  patient  dies  in  this  state  of 
collapse,  post-mortem  examination  may  reveal  a  localized  blood-clot  or 
a  slight  amount  of  laceration  of  the  brain  substance  under  the  point  of 
injury  or  at  the  opposite  i)ole  of  the  brain.  In  some  cases  minute  hem- 
orrhages are  found  throughout  the  substance  of  the  brain,  in  other  cases 
no  change  whatever  is  found  excej^t  perhaps  a  congestion  of  the  vessels 
of  the  pia  mater. 

A  number  of  theories  have  been  put  forth  to  explain  the  profound 
effects  produced  by  blows  which  are  not  associated  with  any  gross  lesions 
of  the  brain,  but  which  yet  produce  most  serious  effects  upon  the  ner- 
vous centers.  The  prevalent  theory  is  that  of  Duret,  that  the  effects  are 
produced  mainly  through  the  sudden  driving  of  the  cerebro-spinal  fluid 
from  the  subarachnoid  space  through  the  foramen  Magendie  into  the 
fourth  ventricle  and  thence  into  the  central  canal  of  the  spinal  cord,  and 
through  the  acjueduct  of  Sylvius  into  the  ventricular  cavities.  The  fatal 
objection  to  this  theory  is  that,  as  shown  by  Kocher  and  Ferrari,  pressure 
in  the  intracranial  cavity  is  transmitted  in  all  directions,  as  in  a  fluid,  so 
that  the  pressure  in  the  ventricles  can  never  be  any  less  than  that  out- 
side the  ventricles.  The  theory  which  appears  most  to  satisfy  the  re- 
quirements is  that  which  has  l3een  recently  worked  out  by  Mr.  Victor 
Horsley,  and  which  has  been  described  with  great  clearness  by  Dr.  S.  B. 
Kramer,  of  Cincinnati.*  It  is  based  on  a  number  of  experiments  in 
which  the  blood-pressure  curve,  the  respiratory  curve,  and  the  intra- 
cranial tension  were  simultaneously  registered.  It  was  found  that  when 
a  sudden  severe  blow  was  given  uj)on  the  skull  there  was  an  immediate 
and  sudden  rise  of  intracranial  tension  ;  in  other  words,  the  sudden  blow 
compressed  the  elastic  skull  and  squeezed  the  contents  of  the  brain,  pro- 
ducing an  instantaneous  and  severe  compression  of  the  brain.  The  brain 
substance,  it  is  true,  is  only  very  slightly  compressible  (Adamkie\\dcz), 
I)ut,  as  these  experiments  show,  a  slight  amount  of  compression  can  be 
made,  and  the  force  of  the  blow  produces  this  effect.  The  compression 
exerts  its  force  mainly  upon  the  soft-walled  blood-vessels,  that  is,  the 
capillaries.  The  blood  is  driven  out  into  the  veins  and  thence  into  the 
extracranial  circulation.  As  a  result,  therefore,  of  this  sudden  compres- 
sion and  rise  of  intracranial  tension  there  is  an  extreme  thoTigh  very 
brief  anaemia  of  the  brain  produced.  This  anaemia  affects  the  parts  sup- 
plied by  the  capillaries,  which  are  essentially  the  cortex  and  ganglia  of 
the  brain.  There  is,  therefore,  produced  in  concussion  of  the  brain  a 
sudden  intense  asphyxiation  of  the  important  nerve  centers,  and  as  a 
result  of  this  their  functions  are  suspended.  In  the  process  of  restora- 
tion of  tlieir  functions  there  is  necessarily  some  disturbance  due  to  the 
sudden  and  violent  disarrangement  of  the  vascular  equilibrium,  and  this 

*  Cincinnati  Lancet  Clinic,  January  27,  1894. 


THE   TRAUMATIC  NEUROSES.  .30r> 

distiirbiince  is  accompanied  pc'rliup.s  with  dilatation  and  rupture  of  small 
vessels.  After  concussion  there  arise  sometimes  a  long  train  of  nervous 
symptoms,  -which  I  shall  describe  later. 


SPECIAL  DESCRIPTION  OF  THE  TRAUMATIC  NEUROSES,  IN- 
CLUDING  TRAUMATIC   NEURASTHENIA,   MIXED   TYPES, 
TRAUMATIC   NEUROSIS   OF    GRAVE   TYPE,   ^VND 
TRAUMATIC   HYSTERIA. 

Tlie  effects  of  concussion  and  shock  having  in  a  measure  passed  away, 
the  patient  sometimes  develops  some  form  of  chronic  functional  nervous 
disorder,  to  which  the  general  term  "traumatic  neurosis"  is  applied;  or 
without  concussion,  and  with  only  some  slight  psychic  shock  and  physical 
injury,  similar  symptoms  may  arise.  It  is  tliis  class  of  disorders  which 
I  shall  now  specifically  describe. 

'^Etiology. — While  the  exciting  cause  of  the  traumatic  neuroses  is 
alwa3''S  trauma,  there  are  many  conditions  which  prepare  and  ripen  the 
system  for  a  nervous  disease,  and  these  causes  will  be  considered  first. 

Age. — The  period  of  life  most  susceptible  to  the  traumatic  neuroses 
is  that  between  the  twentieth  and  fortieth  year ;  that  is  to  say,  the  most 
active  years  of  our  existence.  The  cases  occur  oftenest  in  the  decade 
twenty-one  to  thirty,  next,  thirty-one  to  forty.  Practically  no  cases 
occur  after  the  sixtieth  and  very  few  before  tlie  twentieth  year.  Tliis 
is  shown  in  the  following  table  of  cases  of  traumatic  neurasthenia,  hys- 
teria, and  hystero-iieurasthenia,  compiled  from  cases  reported  by  Erich- 
sen,  Page,  Berbez,  Oppenheim,  Weill,  Knapp,  Dercum,  Bremer,  Clevenger, 
and  myself. 

Ages.  All  Cases.  American  Cases. 

10  to  20  7  4 

21  to  30  52  25 

31  to  40  50  19 

41  to  50  40  11 

51  to  60  16  4 

61  1  1 

166  64 

The  youngest  cases  were  boys  aged  ten  and  a  half  and  twelve,  who 
had  hystero-neurasthenic  troubles  from  a  fall  on  the  head,  (Weill.) 
The  average  age  of  the  French  hysterical  cases  (Berbez)  is  twenty-five 
years,  the  male  cases  being  the  older.  The  ordinary  neiu'asthenic  cases 
are  more  frequent  between  the  ages  of  thirty  and  forty.  The  fact  that 
people  between  the  ages  of  twenty  and  forty  travel  more  and  are  more 
exposed  to  injuries  has  something  to  do  with  the  prevalence  at  this 
period.  Still,  the  first  two  decades  of  life  enjoy  a  great  though  not  abso- 
lute immunity.  In  this  country  the  neurasthenic  cases  occur  more  fre- 
quently in  the  earlier  decades.  This  is  a  peculiarity  which  I  have  noticed 
of  other  neuroses,  such  as  megi'im,  chorea,  and  ei)ilepsy. 

Sex. — Traumatic  neuroses  occur  in  men  often er  than  in  women,  in  the 
proportion  of  3  to  1  (144  to  52).  Traunnitic  neurasthenia  occurs  relatively 
oftener  in  men  (2  to  1).  This  relative  excess  of  the  male  is  due  partly 
perhaps  to  the  greater  frequency  with  Avliich  men  travel  and  are  exposed 


806  -4   SYSTEM  OF  LEGAL  MEDICINE. 

to  accidents ;  perhaps  also  to  some  extent  to  tlie  great  readiness  of  men 
to  resent  injnry  and  to  attempt  litigation.  Still  tlie  same  excess  exists 
in  neurasthenia  due  to  other  causes.  The  German  statistics  give  a  much 
larger  percentage  of  males.  Among  33  cases  of  Oppenheim's  only  2  were 
women. 

Previous  Condition  of  Health. — There  is  a  very  fii-m  conviction 
among  most  neurologists  that  a  neurotic  constitution  or  some  condition 
of  ill-health  exists  in  a  large  proportion  of  the  genuine  cases  of  traumatic 
neuroses.  This  is  certainly  true  for  some  types  of  hysteria,  and  to  a  less 
extent,  in  my  experience,  in  neurasthenia.  Those  cases  which  develop 
degenerative  diseases  of  the  central  nervous  system  have  in  some  cases 
been  infected  with  syphilis,  or  have  been  accustomed  to  excesses  in  alco- 
liol  and  vener}'-,  or  have  been  subject  to  strain  and  privation.  Sexual 
excess  stands  in  especially  important  relation  with  hysteria.  I  have 
known  slight  trauma  to  bring  out  an  attack  of  nervous  syphilis,  and  to 
cause  its  exacerbation  in  quiescent  cases.  I  have  known  also  trauma  to 
excite  chorea  and  afterward  hysteria  in  a  patient  who  had  Bright's  dis- 
ease. This  factor  of  previous  condition  of  health  and  personal  predis- 
position to  nervous  disease  ought  to  be  very  carefully  considered  in  esti- 
mating the  responsibility  of  a  person  or  corporation  for  injury. 

Rigler  thinks  that  railway  officials  are  predisposed  to  traumatic  neu- 
roses, on  account  of  the  irritation  of  the  nervous  centers  from  the  con- 
tinual vibration.  This  may  be  true  of  locomotive  engineers,  who  espe- 
cially suffer  from  concussion,  and  who  are  also  subject  to  much  mental 
strain.  Statistics  show  that  it  is  not  true  of  other  employees,  and  there 
are  not  enough  facts  at  hand  to  enable  me  to  speak  positively  about  the 
engineers.  They  sometimes  develop  neurasthenic  conditions  simply  from 
the  nature  of  their  work,  just  as  other  people  do. 

Concentration  of  Population. — Dr.  W.  B.  Outen,  chief  surgeon  of 
the  Missouri  Pacific  Railroad  Company,  finds  that  traumatic  neuroses 
develop  much  more  frequent^  in  the  neighborhood  of  populous  cities. 
Thus,  among  814  injuries  to  passengers  occurring  at  points  remote  from 
cities,  only  6  eases  of  traumatic  neurosis  developed,  while  among  30 
passengers  injured  on  suburban  trains  there  were  5  cases  of  traumatic 
neurosis.  Furthermore,  among  18,275  injured  employees  only  8  were 
credited  with  traumatic  neuroses,  4  of  whom  recovered.  There  were, 
however,  767  injuries  to  the  back  of  various  kinds.  Among  injured 
passengers  there  was  1  neurosis  to  76-1^- ;  among  employees,  1  in  2248|. 
The  employees  were  all  taken,  however,  and  promptly  treated  in  the- 
company's  hospitals.  Dr.  Outen's  view  that  many  of  the  cases  of  neu- 
rosis were  the  result  of  suggestion  and  litigation  is  no  doubt  in  a  measure 
true.  It  may  be  said,  however,  that  people  living  in  remote  districts 
are  not  so  able  to  fight  for  their  just  rights,  and  are,  as  a  whole,  more 
ignorant  of  a  corporation's  responsibility.  Mr.  Frank  Loomis,  attorney 
for  the  New  York  Central  and  Hudson  River  Railroad  Company,  tells 
me  that  very  few  cases  of  traumatic  neuroses  occur,  in  his  experience, 
on  that  company's  lines. 

Condition  at  Time  of  Injury. — There  is  no  doubt  that  persons  who 
are  injured  while  asleep  or  intoxicated  are  less  liable  to  severe  neuroses. 
This  is  partly  due  to  the  fact  that  the  element  of  fright  and  psychical 
shock  is,  in  a  measure,  eliminated  in  these  cases,  and  partly  to  the  re- 
laxed condition  of  the  body,  which  renders  the  physical  shock  less  violent. 


THE    TRAUMATIC  XEUltOSES.  307 

Persons  wlio  are  acoustoiiied  to  travel,  and,  like  old  soldiers,  are  some- 
what innred  to  the  po.ssil)ilities  of  aeeidents,  are  less  likely  to  be  injured 
than  inexperienced  trav'elers,  who  are  full  of  apprehensions  at  every  sug- 
gestion of  dauii'er. 

Condition  Subsequent  to  Injury. — Persons  who  are  promptly  and 
propei'ly  eared  for  after  accidents  are  less  liable  to  become  nervous.  The 
innnediate  resumption  of  severe  work  and  the  careless  use  of  stimulants 
and  narcotics  no  douljt  favor  the  development  of  nervous  symptoms,  if 
such  were  destined  to  appear.  More  than  all  this,  however,  is  the  effect 
upon  the  patient  of  the  attentions  of  lawj^ers  and  unwise  physicians  who 
are  trying  to  make  out  a  case.  The  worriment  of  litigation  naturally 
Tjrings  out  and  intensifies  many  symptoms.  On  the  other  hand,  many 
t^'pical  cases  of  traumatic  neurosis  occur  when  no  litigation  exists ;  and 
the  attempt  to  put  down  even  the  majority  of  eases  of  traumatic  neuroses 
to  suggestion  and  litigation  is  quite  unjustifiable.* 

The  foregoing  description  of  the  causes  of  the  traumatic  neuroses  ap- 
plies to  all  forms  of  the  functional  nervous  troubles.  In  undertaking  to 
describe  the  symptoms,  however,  it  is  necessarj^  to  make  certain  clinical 
types,  and  describe  these  separately.  As  I  have  studied  these  nem-oses 
they  can  be  mostly  grouj)ed  under  the  head  of : 

1.  Traumatic  Neurasthenia. 
{a)  Mixed  Types. 

2.  Traumatic  Neurosis  of  Grate  Type. 

3.  Traumatic  Hysteria. 

Symptoms  of  Traumatic  Neurasthenia  (Railway  Spine). — The  ner- 
vous symptoms  which  follow  shock  and  injury,  and  wliich  take  the  neu- 
rasthenic type,  are  not  always  alike,  though  they  bear  a  general  resem- 
blance to  each  other  and  to  neurasthenic  states  from  other  causes.  The 
most  common  series  of  phenomena  is  that  which  may  be  grouped  under 
the  head  of  a  simple  traumatic  nem-asthenia.  Tlie  history  of  a  patient 
is  something  like  the  following : 

After  receiving  an  injury  which  is  often  but  slight,  but  which  is  usually 
accompanied  with  a  gi-eat  deal  of  fright  and  emotional  disturbance,  the 
patient  goes  to  his  home  feeling  perhaps  a  little  nervous  and  shaken,  but 
not  suffering  to  any  great  extent.     He  goes  to  bed  and  sleeps ;  wakes  up 

*  There  are  175,233  miles  of  railroads  in  the  United  States,  and  in  the  year  1892, 
575,769,678  passengers  were  carried.  One  person  is  killed  yearly  out  of  every  3,800,000 
passenger  trips  taken,  and  there  is  one  death  to  every  4,600.000  miles  traveled  in  the 
United  States.  The  frequency  of  fatal  accidents  in  this  country  is  -^  times  gi-eater 
than  that  in  the  United  Kingdom.  This  is  due  to  the  fact  that  our  railroads  are  more 
clieaply  built  and  more  numerous,  and  that  there  is  proportionately  a  greater  amount 
of  travel  upon  them.  OoUisions  are  the  cause  of  nearly  one  half  of  tlie  train  accidents, 
and  these  accidents  are  due  in  ten  percent,  of  cases  to  road  defects  and  in  about  fifty 
percent,  of  cases  to  negligence.  (H.  G.  Prout,  XortJi  Awerivan  Ihvh'U-  and  Poor's 
M(i»ii(d.)  As  showing  the  frequency  of  accidents  in  a  large  city,  I  have  obtained, 
tlirough  the  courtesy  of  the  New  York  City  Board  of  Health,  the  "statistics  as  to  the 
mortality  rate  from  accidents  due  to  injuries  received  on  the  elevated,  street  railroads, 
and  other  vehicles  in  tliis  city. 

Deaths  caused  by  street  accidents  in  New  York  City  in  the  year  1892  :  elevaled  rail- 
roads, 8 ;  other  steam  railroads,  5G ;  street  raihoads,  49 ;  other  vehicles,  73  :  total,  186. 


308  A   SYSTEM  OF  LEGAL  MEDICINE. 

the  next  morning:,  feeling  not  quite  as  well  as  nsual,  but  eongTatulating 
Mmself,  perhaps,  on  having  gotten  off  so  easih^  He  resumes  his  work 
and  finds  that  he  can  do  it,  though  with  not  quite  so  much  ease  as  usual, 
and  he  very  likely  suffers  from  some  pain  due  to  a  strain  or  bruise-  that 
he  has  received.  In  a  few  days,  almost  always  within  a  week,  he  begins 
to  notice  that  he  is  more  nervous  than  usual,  that  Httle  things  irritate 
him  which  did  not  do  so  before,  that  his  head  seems  somewhat  confused, 
and  that  the  effort  to  work  is  wearjing.  His  sleej)  is  disturbed,  and  he 
wakes  up  in  the  morning  uni'efreshed  by  his  night's  repose.  He  becomes 
somewhat  despondent  over  his  condition,  and  thoughts  of  paralysis  or 
some  other  serious  aihuent  annoy  him.  His  head  aches,  the  pain  being 
more  or  less  constant  and  diffused,  and  located  usually  over  the  forehead 
or  at  the  back  of  the  neck.  He  has  unpleasant  sensations  in  the  head, 
such  as  that  of  constriction  or  pressui'e  or  scalding  feehngs.  His  back 
also  is  continually  painful,  and  walking  increases  it.  His  nervousness 
becomes  more  marked,  and  close  examination  shows  a  little  fine  tremor 
in  the  hands.  He  has  also  sometimes  creeping  sensations  over  the  body 
or  numb  feehngs  in  the  extremities.  He  tires  very  easily.  He  is  emo- 
tional, and  becomes  more  despondent  as  the  days  go  on.  Sometimes 
he  has  sj)ots  before  his  eyes,  noises  in  his  head,  or  ringing  in  the  ears. 
Eeading  is  laborious  and  increases  his  headache ;  so  also  does  attention 
to  work.  His  appetite  becomes  capricious  and  his  bowels  are  constipated. 
He  suffers  somewhat  from  flatulency  and  dyspepsia.  His  heart  palpitates 
easil}^,  and  the  pulse  is  a  little  accelerated.  Sometimes  for  a  few  days 
there  is  a  little  weakness  about  the  liladder  or  irritabihty  of  that  discus. 
His  sexual  power  is  diminished ;  his  cu'culation  seems  rather  poorer  than 
usual.  Verj^  sUght  excitement  produces  sweating  of  the  hands  or  cold- 
ness of  the  extremities.     He  loses  a  little  flesh. 

These  s}Taptoms  may  be  several  weeks  in  developing,  and  during  this 
time  he  may  perhaps  consult  a  lav^^^er  aliout  his  case.  If  so,  the  anxieties 
of  litigation  begin  to  add  to  and  intensify  his  troubles.  He  consults  a 
physician,  and  the  physician  finds  the  subjective  sATuptoms  that  I  have 
mentioned.  Objectively,  when  examined,  the  physician  mil  discover 
that  the  muscular  power  is  somewhat  weakened,  that  there  is  a  certain 
amount  of  fine  tremor,  perhaps  in  his  hands.  The  knee-jerks  and  ell)ow- 
jerks  are  exaggerated ;  there  are  tender  points  along  the  spine  and  upon 
the  head.  On  making  liim  stand  with  his  eyes  closed  there  is  a  certain 
amount  of  static  ataxia  discovered.  The  pupils  are  often  dilated  and 
mobile,  and  examination  of  the  ^dsual  field  shows  sometimes  a  slight  con- 
traction, at  other  times  the  ''  shifting  t}T3e,"  to  be  described  later.  In 
many  cases  a  degi^ee  of  peripheral  retinal  anaesthesia  will  be  discovered. 
The  pulse  will  be  found  accelerated,  and  pressm-e  on  a  tender  point  wilL 
send  it  up  very  rapidly ;  a  slight  exertion  "will  also  accelerate  it.  There 
will  be  something  api^arent  in  the  physiognomy  of  the  case  which  shows 
the  man  to  be  in  a  nervous  and  asthenic  condition.  Sometimes  the  pains 
from  which  the  patient  suffers  in  the  back  and  the  weariness  in  the 
limbs  are  so  great  that  he  remains  a  good  deal  of  the  time  in  bed.  In 
all  cases  he  will  assert  most  positively  that  he  is  unable  to  work  or  to 
take  that  interest  in  his  affairs  that  he  has  previously  done.  In  a  good 
many  cases  there  will  be  added  to  the  foregoing  picture  a  number  of 
symptoms  due  to  some  local  injury :  for  example,  the  arm  may  have  been 
wrenched  or  bruised,  and  the  result  may  be  a  certain  amount  of  neuritis 


TIIK   Th'.lVMJriC  NEUROSES.  ?,09 

and  wcakiK'SS  or  pain  in  lliat  nioinlxT;  in  otlicr  cases  the  hack  may  Lave 
been  so  severely  sprained  tliat  the  typical  symptoms  of  spinal  irritation 
ensue,  and  this  is  pai-ticularly  apt  to  he  the  case  when  Avomen  are  injured. 
In  other  eases,  again,  the  lej^s  may  have  l)een  hurt  to  such  an  extent  that 
a  sciatica  or  some  other  form  of  neuralgia  develops. 

The  foregoing  symptoms,  varying  in  amount  and  degree,  will  last, 
with  little  change,  for  a  very  long  period  of  time.  If  the  case  goes  into 
litigation,  there  is  added  the  worriment  o(;(;asioned  by  having  to  go 
through  the  disturbing  experiences  of  trial  by  jury.  lu  many  cases, 
after  the  trial  has  been  settled  and  damages  awarded  or  otherwise,  the 
patient  begins  to  mend,  and  in  a  certain  proportion  of  cases  he  gets  com- 
pletely well.  This  is  not  by  any  means  invariably  the  rule ;  it  may  be 
said,  on  the  contrar}^,  that  as  a  general  thing  a  person  who  receives  a 
serious  shock  to  his  nervous  centers,  residting  in  a  genuine  and  grave  neu- 
rasthenia, is  i-arely  entirely  the  same  afterward.  However,  after  a  varia- 
ble period  of  months  or  years  most  cases  get  into  a  state  of  at  least 
comparative  health.  Their  nervousness  gradually  diminishes,  their  sleep 
improves,  the  pains  successively  lessen,  the  appetite  is  restored,  the  fieshi 
is  regained,  the  power  of  work  and  enjoyment  in  life  come  back. 

MIXED   TYPES. 

Traumatic  Spinal  Irritation. — Besides  the  foregoing  general  and 
common  sjnnptoms  of  traumatic  neurasthenia,  it  sometimes  affects  per- 
sons in  other  and  special  modes.  For  example,  the  sjanptoms  of  spinal 
irritation  may  predominate.  These  form  the  cases  which  were  described 
b}^  Erichsen  under  the  head  of  sjnual  antemia  aud  hypertpmia.  Their 
symptoms  differ  little  from  those  described  in  systematic  works  upon  spi- 
nal irritation.  These  patients  are  usually  women.  After  receiving  an 
injury  which  may  have  been  slight  and  which  may  not  necessarily  have 
directly  injured  the  spine,  they  very  soon  complain  of  pains  in  the  back  and 
2)articularly  the  lower  end  of  the  spine  and  in  the  back  of  the  neck.  These 
pains  are  so  severe  that  they  soon  give  up  attempting  to  walk  about,  and 
linding  that  they  get  some  relief  and  comfort  in  bed  they  go  there  and  there 
i-em ai n.  While  keepin g  perfectly  cpiiet  the  l;)ack  gives  them  comparatively 
little  discomfort,  l)ut  attempts  to  sit  up  for  a  long  time,  to  ride,  or  to  walk, 
cause  such  distress  that  they  are  speedily  abandoned.  The  pains  are  of  a 
heavy,  aching  eluxracter,  increased  until  they  become  very  sharp  Avhen 
attempts  at  movement  of  Wia  trunk  are  made.  There  is  a  great  deal  of  ten- 
derness to  pressure  alongthe  spinal  processes,  some  of  these  processes  bein^ 
much  more  sensitive  than  others.  The  most  sensitive  points  are  usually 
the  back  of  the  neck  and  the  upper  dorsal  vertebrjT3,  and  down  in  the  lum- 
bar region.  There  is  some  pain  also  upon  pressure  alongside  of  the  spinal 
processes.  Painful  points  often  vary,  and  even  in  a  single  examination 
the  patient  may  complain,  and  complain  honestly,  of  dilferent  si^nsitive 
vertebrae  They  suffer  much  from  headaches.  The  arms  are  often  weak, 
so  that  attempting  to  sew  or  write  or  hold  a  book  causes  pain  in  the  neck 
and  shoulders.  The  legs  are  also  weak  and  the  circulation  poor.  There 
is  sometimes  palpitation  of  the  heart  and  precordial  distress,  A  certain 
amount  of  dyspepsia  is  always  pi-esent,  and  constipation  is  the  rule.  The 
patients  often  have  attacks  of  vomiting,  and  attempts  to  feed  them  re- 
(piire  much  care.     The  menstrual  functions  become  irregular,  aud  if  it 


310  ^   SYSTEM  OF  LEGAL  MEDICINE. 

be  a  male  tlie  genital  functions  are  weak,  Tlie  knee-jerks  are  exagger- 
ated;  but  there  is  never  any  true  ankle-clonus.  There  is  no  ana?sthesia 
of  the  skin,  and  we  rarely  detect  any  anaesthesias  of  the  special  senses. 
I  have  never  been  able  to  find  contraction  of  the  visual  field  or  of  the 
aural  field,  nor  do,  in  this  country,  the  anaesthetic  stigmata  of  hysteria 
present  themselves.  The  patients  are  mentally  very  emotional  and  de- 
pressed. The}^  complain  much  al^out  their  pains ;  they  are  irritable  and 
exacting ;  their  sleep  is  very  j)oor  and  often  requires  hypnotics.  They 
have  frequent  intense  headaches,  which  are  usually  of  a  congestive  char- 
acter— that  is  to  say,  are  associated  with  feelings  of  fullness  in  the  head 
and  throbbing,  spots  before  the  eyes,  and  ringing  in  the  ears.  If  such 
patients  have  become  thorough^  bedridden,  their  symptoms  are  ex- 
tremely aj)t  to  become  chronic,  and  they  form  a  very  difficult  class  to  deal 
with.  After  a  time  the  legs  waste  considerably,  and  there  may  be  even 
a  certain  amount  of  actual  paralysis — that  is  to  say,  the  limbs  are  too 
weak  to  support  them  and  too  weak  to  respond  to  any  severe  test  of 
muscular  strength.  Electrical  examinations,  however,  never  show  any 
of  the  evidences  of  degenerative  reaction.  Cases  of  this  kind  may  con- 
tinue for  two  or  three  years,  their  sjanptoms  then  gradually  ameliorate, 
and,  as  a  rule,  they  get  better,  if  not  entirely  well.  A  few  cases  continue 
with  more  or  less  painful  spines  and  weak  extremities  for  a  great  many 
years.* 

Hypochondriacal  Neuroses. — There  is  another  form  of  traumatic  neu- 
rosis, wliich  is,  strictly  speaking,  a  psychical  disorder  or  form  of  hysteria. 
It  is  characterized  by  the  existence  of  certain  fixed  ideas  or  a  fixed  idea 
regarding  some  morbid  condition  of  the  body.  The  special  direction  or 
2Doint  toward  which  the  mind  is  fixed  varies  somewhat,  being  often  de- 
termined in  a  measure  b}^  tlie  original  injury.  Sometimes  it  is  simpty  a 
23ainful  spot  in  certain  parts  of  the  bod}",  such  as  the  back  or  the  head ; 
or  it  may  be  a  painful  joint,  and  develop  into  a  so-called  "hysterical  joint"  ; 
sometimes  it  is  a  morbid  condition  of  the  stomach  or  of  the  sexual  func- 
tions which  alarms  and  depresses  the  patient.  The  special  symptom  about 
which  the  patient's  mind  is  centered  is  the  only  prominent  trouble  that 
he  has,  but  it  is  generally  associated  with  a  certain  amount  of  dyspepsia 

*  TrciKviatic  Fanctlonal  Parali/ses. — There  seems  to  be  no  doubt  that  occasionally 
patients  suffer  from  functional  paraplegia,  which  is  essentially  of  spinal  origin  rather 
than  cerebral.  The  cases  resemble  in  many  respects  those  jxist  described.  The  pa- 
tients who  suffer  from  this  condition  are  generally  women  at  the  adolescent  period  of 
life,  and  their  paralysis  occurs  in  connection  with  symptoms  of  pains  in  the  back  and 
a  general  neurasthenic  state.  These  cases  have  often  been  described  under  the  heads 
of  spinal  ana'niia  and  of  hysterical  paraplegia.  Bastian,  in  his  work  on  Hi/sferical  or 
Functional  Parahjsis,  believes  them  to  be  due  to  a  functional  disorder  of  the  anterior 
cornual  cells  or  of  the  pyramidal  tracts  in  connection  with  the  anterior  honis.  The 
paralyses  of  this  kind  are  not  by  any  means  as  a  rule  caused  by  trauma,  but  more 
often  they  develop  gradually  through  the  influence  of  overwork  or  some  exhausting 
disease.  Occasionally,  however,  they  do  develop  after  an  inJTiry.  In  some  there  is 
a  history  of  tuberculosis.  The  onset  of  the  trouble  is  usually  gradual.  The  patients 
suffer  from  a  progressive  eufeeblement  of  the  lower  limbs,  associated  with  pains  in 
the  back  and  a  sense  of  heaviness  and  weariness  in  the  affected  extremities.  The 
<.'irculation  of  the  lower  limbs  is  somewhat  feeble,  and  the  skin  looks  white  and  feels 
«ool  and  clammy.  Tliere  is  no  decided  muscidar  atrophy,  and  there  are  no  cpialitative 
changes  in  the  electrical  reactions.  The  knee-jerks  and  skin  reflexes  are  usually  ex- 
aggerated. No  special  group  of  muscles  is  affected  more  than  others.  There  may  be 
a  little  bladder  weakness,  but  it  is  not  serio;is  or  permanent.  There  is  rarely  any 
anaesthesia,  and  if  present  it  is  only  very  slight  in  grade.     There  is  pain  in  the  back 


THE   TRAUMATIC  NEUIIOSES.  811 

and  constipation,  with  a  condition  of  iin]>airod  nntrition,  general  weak- 
ness, a  good  deal  of  mental  iiTital)ility,  and  always  with  mental  depres- 
sion. The  most  searcliino'  exaniinati(m  of  the  bodily  functions  fails  to 
discover  any  sign  of  organic  disease  or  any  evidence  of  sei-ions  disturb- 
ance of  the  nervous  function ;  yet  desi)ite  this  the  patient  incessantly  (ioni- 
plains  and  talks  continually  about  his  sufferings.  This  immense  dispro- 
portion between  the  sid)jective  suifering  of  the  patient  and  the  objective 
jsyniptoms  constitutes  the  cliaraeteristic  feature  of  the  disorder.  It  is  not 
accompanied,  I  should  add,  with  those  stigmata  which  are  associated  with 
decided  forms  of  neurasthenia. 

This  neui'osis,  which  is  also  called  JnjjMtrJioiidridsis,  usually  occurs  in 
persons  who  have  a  psychopathic  history — i.e.,  in  persons  who  have  always 
been  self-centered  and  of  a  neurotic  temperament.  Cases  of  traumatic 
arthralgia  and  so-called  topoalgia  belong  to  this  class.  In  connection 
with  ti-auma  true  h3^pochondriases  and  arthralgias  are  in  my  experience 
rare ;  though  these  conditions  not  infrecpiently  complicate  genuine  neu- 
rasthenic states.  A  somewhat  typical  case  of  this  form  of  disorder  is  the 
following : 

J.  K.,  aged  twenty-eight ;  nativity,  United  States ;  single ;  occupa- 
tion, barten  der.  The  patient  gives  a  family  history  which  is  compar- 
atively free  from  neurotic  incidents.  His  father  suffered  from  chronic 
headache,  but  was  otherwise  healthy.  There  is  no  tubercidosis  in  the 
family.  He  himself  had  always  been  a  fairly  healthy  man,  though  of  a 
nervous  and  somewhat  irritable  temperament.  He  had  megi-ainous  head- 
aches, beginning  at  about  the  age  of  twenty-two.  Tlu'ee  and  a  half  years 
before  I  saw  him  he  had  a  fall  through  a  trap-door.  He  got  no  severe 
injury  and  was  not  stunned.  He  got  up  and  went  about  his  work  as 
usual.  In  the  course  of  six  or  eight  weeks  he  began  to  notice  a  jiain 
developing  in  the  back  between  the  shoulder-blades,  which  he  put  into 
relation  with  the  strain  experienced  during  the  fall.  This  pain  was  of 
a  dull,  aching  character ;  it  did  not  pass  around  the  chest,  but  was  con- 
fined to  an  area  atiout  the  level  of  the  fourth  dorsal  vertebra  on  the  left 
side,  between  the  vertebra  and  the  scapida.  The  pain  was  constant, 
never  disappearing  during  the  day-time,  not  improved  by  posture,  not 

sometimes,  but  not  in  the  legs.  Tlie  i^aralysis  may  be  incomplete,  the  patient  being 
able  to  stand  and  take  a  few  steps  ;  sometimes,  however,  it  is  so  severe  that  t]ie]>atient 
is  bedridden,  although  she  never  loses  entirely  the  power  of  moving  the  lower  limbs 
while  lying  in  bed.  After  a  time  contractures  take  place  in  some  cases  and  the  legs 
are  drawn  np.  Along  with  this  a  considerable  amount  of  wasting  occurs,  but  there 
are  still  no  electrical  changes  characteristic  of  degeneration.  The  spine  is  tender  to 
pressure,  and  tlie  patient  often  suffers  great  distress  in  tlie  back,  particularly  in  the 
lower  part  and  in  the  cervical  region.  The  arms  are  usually  unaffected.  The  patient 
presents  absolutely  none  of  the  characteristic  hysterical  stigmata,  such  as  anaesthesias 
of  glove  and  stocking  type,  contracted  visual  field,  pharyngeal  anaesthesia,  disturbance 
of  smell  and  taste,  ami  hysterical  crises.  In  fact,  the  picture  of  the  case  is  very  much 
like  that  wliich  I  have  described  Tinder  the  head  of  spinal  irritation;  the  difference 
being  only  tliat  the  dominant  sym]itom  in  this  class  of  cases  is  the  paraplegia,  while 
flie  spinal  and  other  pains  are  simply  associated  with  it.  The  patients  often  take  a 
fair  amount  of  food,  though  they  are  subject  to  digestive  disturbances  and  attacks  of 
'S'oraiting.  They  have  severe  headaches  at  times.  Tlie  heart  action  is  not  strong,  and 
the  arterial  tension  is  low.  Such  forms  of  paralysis  are  often  very  obstinate,  lasting 
usually  from  one  to  four  or  five  years.  As  a  rule  the  patients  get  well,  and  an  active, 
vigorous  treatment  is  an  extremely  important  factor  in  securing  this  end.  In  fact, 
tlie  prognosis  is  vastly  changed  in  accordance  with  the  character  of  the  therapeutic 
•measures  which  the  i)atieut  receives. 


312  ^   SYSTEM   OF  LEGAL  2IEDICIXE. 

increased  by  movement  or  "vvork,  and  not  relieved  by  rest.  At  times 
there  were  exacerbations  of  it,  so  severe  as  to  render  liim  utterly  mis- 
erable, tbongli  thej^  never  incapacitated  Mm  for  bis  work.  His  general 
health  continued  good.  He  was  able  to  eat  and  digest  his  food,  to  sleej), 
and  to  perform  his  daily  work.  His  habits  were  good ;  be  neither  drank 
nor  smoked,  except  in  great  moderation.  No  form  of  treatment  produced 
tbe  slightest  effect  upon  the  suffering,  and  at  the  end  of  three  and  a  half 
years  be  was  brought  to  me  for  examination. 

He  was  a  man  of  strong  and  muscular  build,  somewhat  thin  in  figm-e, 
but  not  emaciated  in  any  degree.  He  presented  some  symptoms  of  a 
catarrhal  dyspepsia,  but  other  than  that  there  were  absolutely  no  object- 
ive symptoms,  nor  were  there  any  of  the  marks  of  hj^steria.  On  ex- 
amining the  painful  area  I  discovered  it  to  be  located  about  as  stated, 
between  the  thu-d  and  fom-th  dorsal  spines,  covering  an  area  of  about 
two  inches  in  diameter  between  these  spines  and  the  inner  border  of  the 
scapula.  Here  there  was  some  hj-per^esthesia  to  touch  and  some  tender- 
ness on  pressui'e.  The  pressm-e  and  manipulation  of  the  spine  produced 
no  pain,  nor  could  jDain  be  elicited  by  any  movements  of  the  trmik  or 
shoulders.  The  pain  was  relieved  only  temporarily  by  injections  of  co- 
caine. It  was  not  helped  by  cauterization,  blisters,  or  counter-irritants 
of  any  kind.  In  fact,  no  local  application  or  any  internal  medication  did 
the  slightest  good. 

UNUSUAL   TYPES. 

There  are  certain  pecidiar  forms  of  traimiatic  neui-osis  which  cannot 
be  classed  strictly  under  any  of  the  foregoing  heads.  These  atypical 
forms  of  traumatic  neui-osis  have  uot  been  observed  in  sufficient  number 
as  yet  to  enable  us  to  make  of  them  a  tx])e.  I  shall  therefore  not  at- 
tempt a  systematic  description  of  them,  Imt  shall  place  on  record  a  case 
which  iLLustrates  veiy  well  the  class  of  injury  to  which  I  refer,  adding 
that  in  atj^ical  forms  the  probability  of  simulation  or  exaggeration  is 
always  very  gi-eat. 

A.  D.,  aged  forty-five,  married,  had  alwaj^s  been  a  strong,  hard-work- 
ing, -^-igorous  man  of  temperate  habits,  and  without  any  history  of  alco- 
holism or  syphilis  or  previous  nervous  disorder.  In  April,  1892,  while 
standing  in  a  car,  he  was  thrown  down  in  the  aisle  by  the  force  of  a  col- 
lision. He  was  temporarily  stunned,  but  got  up,  sat  in  his  seat  very 
much  frightened,  but  unconscious  of  much  injury.  He  got  to  his  dejDot 
in  fifteen  or  twenty  minutes,  then  found  he  could  not  walk,  and  had  to 
be  lifted  to  a  carriage  which  con^-eyed  him  to  his  home.  His  physician, 
who  was  then  called,  found  that  he  had  a  contusion  of  the  right  parietal 
boss,  severe  pain  in  the  lower  part  of  the  back,  numbness  in  the  left  leg 
below  the  knee  and  in  the  right  arm,  in  the  course  of  the  distribution 
of  the  ulnar  nerve.  There  was  no  anaesthesia  and  no  distinct  paralysis, 
but  rather  a  "^veakness  of  the  legs  and  of  the  right  arm.  Tremor  was 
also  observed  in  the  two  upper  extremities.  The  temperature  was  ninety- 
seven  degi'ees.  Xo  bladder  or  rectal  troiibles.  He  suffered  considerable 
pain  in  the  back  and  in  the  leg.  He  was  placed  in  bed,  and  continued 
in  about  the  same  condition  for  a  week  or  two,  then  gradually  improved 
so  that  he  could  sit  up  and  walk  a  little.  During  tins  time  he  had  chok- 
ing sensations  at  times.      He  slept  and  ate  pretty  weU,  but  was  uer^-ous, 


THE    TEA  IMA  TIC  yELTlOSES.  3  "13 

depressed,  emotional,  and  irritable.     He  had  durin^-  this  time  a  slijL^ht 
attack  of  herpes  zoster  over  the  eonrse  of  the  rij^'ht  twelfth  dorsal  nerve. 

He  was  seen  hy  nie  al)out  six  months  after  the  injur}'.  The  physical 
examination  at  that  time  showed  him  to  l)e  a  man  of  good  color,  not 
ana'mie,  well  nourished.  He  walked  slowly,  using  a  cane,  and  spreading 
his  feet  apart.  He  was  unable  to  stand  with  e^^es  closed.  There  was  no 
atroi)hy  of  any  muscular  groups  in  any  of  the  extremities.  He  had  a 
fine  tremor  of  considerable  amplitude,  continuous  in  character,  increased 
on  extension  of  the  arm,  and  slightly  on  volitional  movement.  There 
was  some  tremor  in  the  legs  and  a  very  little  in  the  face  and  tongue. 
On  making  him  shut  his  ej'cs  and  show  his  teeth  a  pecidiar  shai-])  con- 
traction of  tlie  platysma  myoides  was  produced  (perha|)S  natural  to  him). 
The  tactile,  temperature,  and  pain  sensations  were  all  normal.  There 
was  a  slight  degree  of  ataxia  in  the  legs,  Imt  none  in  the  arms.  There 
was  a  slight  amount  of  tenderness  about  the  region  of  the  third  and 
fourth  lundjar  vertebne.  Pressure  and  the  application  of  heat  produced 
some  wincing  and  reflex  contraction  of  muscles  near  the  spinous  pro- 
cesses. He  coidd  move  the  back  and  trunk  in  all  directions.  Pushing 
on  his  legs  caused  pain  in  the  back.  This  luml>ar  pain  never  radiated 
around  the  waist  or  darted  down  the  legs.  There  apjieai-ed  to  be  cf)nsid- 
erable  weakness  in  both  legs,  more  in  the  right,  and  there  was  some 
weakness  in  the  right  arm  as  compared  with  the  left.  No  fibrillary  con- 
tractions. The  knee-jerks  were  exaggerated  slightl}^,  but  there  was  no 
clonus.  There  was  also  exaggeration  of  the  elbow- jerks.  Electrical  re- 
actions of  the  leg  and  arm  muscles  were  normal  or  slightly  increased. 
There  was  no  liypera?sthesia  or  tenderness  except  in  the  back.  The 
special  senses  of  smell  and  taste  were  normal.  The  hearing  was  normal 
except  in  the  left  ear,  where  he  was  deaf  to  high  notes,  bone  and  aerial 
conduction  being  good.  The  pupils  w^ere  small,  equal,  reacted  to  light 
and  acconnnodation.  Vision  was  good,  and  there  was  no  contraction  of 
the  visual  fields.  The  pidse  was  seventy-two  and  the  heart  action  normal. 
The  pharyngeal  reflex  was  normal,  and  the  choking-attacks  which  he  had 
once  suffered  from  had  ceased.  The  urine  was  normal.  He  suffered 
from  cold  feet  and  some  evidences  of  vasomotor  weakness. 

The  diagnosis  at  the  time  was  a  traumatic  neurasthenic  condition, 
plus  some  local  injury  to  the  spinal  ligaments  and  to  some  of  the  nerves 
issuing  between  the  twelfth  doi'sal  and  first  lumbar,  and  between  the 
third  and  fourth  lund)ar  on  the  left  side. 

This  case,  while  to  a  large  extent  functional,  was  perhaps  complicated 
with  a  certain  amount  of  injury  to  spinal  nerves,  and  certainly  with  much 
exaggeration.     The  patient  got  practically  well. 

Special  Symptoms. — Hjxvhig  gone  over  the  symptoms  of  the  vari- 
ous tj^pes  of  traumatic  neui'oses  and  given  some  illustrative  cases,  I  pro- 
pose now  to  discuss  some  of  the  spe{;ial  symptoms  which  we  find  in  these 
cases,  and  which  are  more  or  less  characteristic. 

First  of  all,  I  shall  take  up  those  symptoms  which  Indong  to  the  psy- 
cJiicdl  spJior,  and  which  include  mental  irritability  and  depression,  lack 
of  attention,  lack  of  power  of  concentrating  the  attention,  feebleness  of 
memory,  and  weakness  of  volitional  power.  Associated  with  these  may 
be  classed  the  headaches,  vertigo,  para^sthesia  of  the  head,  including  such 
symptoms  as  insomnia,  head-pressiu'e,  feelings  of  constriction  and  fullness. 
Of  these  symptoms  the  insomnia  is  one  which  is  perhaps  most  characteris- 


314 


A  SYSTEM  OF  LEGAL  MEDICINE. 


Diagrams  showing  in  Figs-  34  and  .35  the  area  over  which  a  cutaneous  irritation  causes  a 
reflex  contraction  of  cremaster ;  siiovving  in  Fig.  36  the  areas  over  which  a  slight  hlow  produces 
a  knee-jerli.    P'roin  a  patient  with  a  traumatic  neurosis. 


THE  TRAUMATIC  NEVBOSES. 


315 


tic,  and  wliicli  may  be  looked  upon  to  a  certain  extent  as  a  symptom  of  an 
objective  character.  Sleep  is  usually  veiy  much  disturbed  by  bad  dreams, 
and  it  is  characterized  especially  by  the  fact  that  when  the  patients  wake 
in  the  morning  they  have  none  of  the  sensation  of  restfulness  that  comes 

from  healthful  slumber.  The  emotion- 
ality and  u-ritability  of  patients  are  alsa 
things  which  are  usuaU}-^  noticed  by  others, 
and  are  in  a  measure  objective.  Little 
things,  which  never  before  annoyed  the 
patient,  now  are  become  a  som-ce  of  con- 
stant annoj-ance ;  they  get  angiy  at  slight 
provocation,  and  become  very  disagree- 
able persons  to  live  Tvith.  They  often 
cry  over  trivial  circumstances,  and  also 
develop  certain  fixed  and  morbid  ideas 
with  regard  to  their  condition  and  the 
future.  The  patient  reacts  very  sensi- 
tively to  stimiilants  and  narcotics. 

The  Muscular  and  Motor  Symptoms. — 
Tremor  is  a  symptom  which  is  very  fre- 
quently present.  It  is  fine  in  character 
and  vibratory,  and  l^rought  out  best  by 
making  the  patient  extend  the  hands  and 
fingers.  It  is  increased  readily  by  a  slight 
amount  of  excitement  and  by  narcotics 
and  stimulants,  such  as  tea,  coffee,  alco- 
hol, and  tobacco.  The  muscular  strength 
is  somewhat  reduced,  as  shown  by  dyna- 
mometer tests  and  by  the  attempts  of  the 
patient  to  do  physical  work.   There  is  usu- 


Fig.  37.    Eyes  closed.  Fig.  38.    Eyes  open. 

Ataxiagram  showing  SAvaying  of  body. 


ally  a  certain  amount  of  wasting  of  muscles,  but  this  wasting  is  general,  and 
does  not  affect  special  groups.  Questions  as  to  the  nornuil  difference  in  the 
size  of  the  extremities  often  arise.  It  has  been  found  by  measurements 
of  normal  adults  that  the  size  of  the  calves  of  the  legs  is  equal  in  about 
one  third  of  the  eases,  and  that  the  right  is  larger  than  the  left  in  about 


316  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

one  tliird,  while  the  left  is  larger  than  the  right  in  somewhat  less  than 
one  fourth  of  the  eases.  The  differences  never  exceed  five  eighths  of  an 
inch,  and  rarely  reach  that  extent.  (Walton.)  The  differences  in  the  size  of 
the  arms  are  more  considerable  relatively,  depending  upon  the  occupation 
and  habits  of  the  indi'sddual,  so  that  the  exact  figures  cannot  be  given. 

Twitching  motions  of  the  face  and  a  slight  amount  of  fibrillary 
contraction  take  place.  In  these  cases  there  is  no  locomotor  or  motor 
ataxia,  but  there  is  always  in  my  experience  a  considerable  degree  of  static 
ataxia,  varjdng  with  the  nervous  dej)ression  and  irritability  of  the  patient. 
This  test  for  static  ataxia  I  consider  an  objective  one  of  considerable 
value.  It  must  be  made,  however,  by  means  of  instruments  of  precision, 
which  record  aeciu-ately  the  amount  of  swapng  of  the  patient  with  the  eyes 
closed  and  with  the  eyes  open.  (See  Figs.  37  and  38.)  Something  further 
will  be  said  upon  this  point  in  connection  with  the  diagnosis.  The  ten- 
don-reflexes are,  as  a  rule,  considerably  exaggerated.  This  exaggeration 
is  shown  by  the  quick  and  extensi^-e  movement  of  the  feet  on  striking 
the  patellar  tendon,  and  by  the  fact  that  it  can  be  brought  out  by  strik- 
ing the  leg  on  or  below  the  knee-cap  and  on  the  quadi'iceps  muscle  above 
for  a  considerable  extent.  This  extensive  area  over  which  a  blow  "wdll 
bring  out  a  reflex  contraction  is  an  objective  indication  of  nervous  iiTi- 
tability  of  value  in  diagnosis.  There  is  also  an  increase  in  the  activity 
and  extent  over  which  the  skin-reflexes  can  be  brought  out.  This  is 
particularly  well  studied  in  connection  with  the  cremasteric  reflex.  (See 
Figs.  34,  35,  and  36,  on  page  314.) 

Ill  the  sensory  sphere  there  are  a  number  of  symptoms  which  eaU  for 
special  study.  In  traumatic  neru-asthenia  there  is  no  anesthesia  of  the 
skin  unless  some  complicating  organic  injiuy  or  some  hysterical  process 
be  present.  In  this  statement  I  know  that  I  am  at  variance  with  the 
teachings  of  some  of  the  German  neurologists.  Oppenheim  in  particular 
lays  stress  upon  the  fact  that  in  traumatic  neuroses  there  are  conditions 
of  slightly  diminished  cutaneous  sensibility  as  well  as  genuine  anaesthesia. 
This  diminished  sensibility  or  hypffisthesia  is,  however,  one  I  have  never 
been  able  to  satisfactorily  demonstrate  in  any  except  i)atients  who  pre- 
sented distinct  hysterical  marks  of  other  kinds  or  in  cases  of  organic 
neurosis,  and  the  diificulties  in  the  way  of  establishing  a  diminished  sen- 
sibility which  may  be  considered  pathological  are  so  great  that  the  symp- 
tom is,  in  my  opinion,  even  if  present,  one  of  little  importance.  There 
is  a  good  deal  of  tenderness  along  the  spine  (in  sixty  to  seventy-five  per- 
cent, of  cases)  at  various  points ;  also  upon  the  scalj),  particulaiiy  at  the 
sutm-es  of  the  bones ;  and  sometimes  in  other  i)ortions  of  the  body.  This 
tenderness  on  pressure  is  looked  upon  as  an  oljjective  s}^nptom,  and  is,  I 
believe,  admitted  as  such  in  courts  of  law.  When  the  test  is  properly 
applied  it  has  a  certain  amount  of  value,  because  the  patient  Avill  not  al- 
ways wince  properly  if  he  is  pressed  unexpectedly  on  points  that  are  not 
really  tender,  and  because,  on  the  other  hand,  the  skillful  apphcation  of 
sudden  pressure  will  bring  out  certain  genuine  manifestations  of  pain. 
In  addition  to  that,  there  is  in  some  cases  a  rather  sudden  acceleration 
of  the  pulse  when  a  tender  point  is  pressed.  This  symptom  was  first 
described  by  Mannkopf  in  1885  and  is  called  after  his  name.  Its  pres- 
ence indicates  an  undue  irritability  of  nerve  centers  and  has  objective 
importance,  though  it  does  not  show  the  existence  necessarily  of  a  trau- 
matic or  other  neurosis. 


THE  TRAUMATIC  NEUROSES. 


317 


318 


A   SYSTEM  OF  LEGAL  MEDICINE. 


Visual  TrouNes. — In  traumatic  neuroses  without  hysterical  compli- 
cations there  is,  as  a  rule,  no  concentric  limitation  of  the  visual  field. 
Still,  slight  limitation  occurs  in  a  minority  of  cases,  and  in  nearly  all  in- 
stances in  which  the  symptoms  are  of  a  severe  type  there  is  evidence 
of  a  certain  amount  of  fatigability  of  the  visual  field.  I  mean  by  this 
that  there  are  evidences  of  a  ver}'  easy  tiring  of  the  periphery  of  retina. 
The  existence  of  this  condition  has  been  pretty  well  established  by  the 
labors  of  Forster,  Konig,  and  others.  My  own  experience  is  that  in  at- 
tempts to  map  out  the  visual  field  in  these  cases  there  is  great  conflict  of 
statement  on  the  part  of  the  patients  with  regard  to  the  position  of  the 
object  that  is  moved  before  them,  showing  that  their  power  of  attention 


Fig.  40,  showing  Forster's  "shifting-type"  in  a  case  of  traumatic  neurosis.  The  contin- 
uous line  represents  the  field  of  Nasion  as  the  test-object  is  moved  from  periphery  to  center; 
the  dotted,  as  the  object  is  moved  in  the  reverse  direction. 


is  easily  exhausted,  and  that  their  power  of  perception  weakens  along 
with  it.  In  some  cases  one  finds  a  general  hmitation  of  the  visual  field 
of  a  moderate  degree,  as  seen  in  the  diagram,  Fig.  39.  In  other  in- 
stances one  finds  a  condition  which  has  been  described  by  Forster  and 
Konig,  and  is  known  as  the  Forster  shlt'ting-type  {ScMehungstypus).  The 
characteristic  of  this  type  is  that  the  field  of  vision  which  is  mapped  out 
by  bringing  an  object  from  outside  toward  the  center  is  greater  than 
the  field  of  vision  mapped  out  by  bringing  an  object  from  the  center  of 
"\dsion  toward  the  periphery.  If,  for  example,  an  object  is  placed  to  the 
temporal  side  of  the  right  eye  and  gradually  brought  forward  until  it  comes 
into  the  field  of  vision,  it  wiU  be  seen,  we  will  say,  at  eighty-five  degrees. 
The  object  is  then  brought  gradually  forward  until  it  reaches  the  center 


THE   TRAUMATIC  NEUROSES.  '319 

of  the  visual  field;  it  is  held  there  an  instant  and  then  moved  gradually- 
back.  As  it  IS  niovcnl  back  it  Avill  be  lost  to  view,  we  will  say,  at  eiglity 
degrees.  The  object  is  then  moved  in  the  same  way  on  the  nasal  side,  and 
above  and  below,  with  the  same  residt.  An  example  of  this  is  sliown  in 
the  diagram  appended  here.  (See  Fig.  40.)  There  is  sometimes  a  disturb- 
ance in  the  color  sense  in  these  conditions,  and  we  often  find  evidence  of 
muscular  asthenopia,  especially  loss  of  power  of  convergence.  (Huebscher.) 
Other  symptoms  are  a  visual  weakness,  with  at  times  spots  before  the  eyes, 
ami  i)ain  and  tenderness  in  the  eyeballs  and  al^out  the  brow.  Patients 
often  complain  of  total  inability  to  read  for  any  but  a  very  short  time. 
Attempts  to  read  produce  headache,  mental  confusion,  and  a  sense  of 
prostration.* 

The  sense  of  smell  is  sometimes  found  to  be  impaired  or  aboHshed 
after  injuries  of  the  head.  It  is,  however,  in  most  cases,  if  not  all,  au 
evidence  of  local  disorder  or  of  some  actual  organic  disease.  Thus, 
among  twenty- two  cases  of  head  injury  which  were  followed  by  anosmia. 
Von  Bergmann  found  evidence  of  fractiu-e  of  the  base  of  the  skidl  in  ten. 
It  is  to  be  remembered,  also,  that  anosmia  is  sometimes  a  sjanptom  in 
tabes  dorsalis,  aud  is  sometimes  produced  by  syphilis. 

Disturbances  in  the  sense  of  taste  are  very  common  in  hysteria,  but 
not  in  traumatic  neurasthenic  conditions.  In  this  latter  class  of  cases 
there  may  be  an  undue  irritability  of  this  sense  or  some  perversion  due 
to  local  conditions  or  digestive  troubles,  but  that  is  aU. 

The  disturbances  of  the  special  sense  of  hearing  consist  of  noises  in 
the  ear,  hyperacusis,  and  sometimes  slight  deafness.  Baginsky  has  de- 
scribed a  deafness  occurring  in  traumatic  neurasthenia,  and  due  to  con- 
cussion of  the  labyrinth.  It  is  associated  with  noises  in  the  head  and 
sometimes  Avitli  vertigo.  It  occurs  especially  after  a  physical  injury. 
Sometimes  vertigo  occurs  and  becomes  extremely  annoying,  and  cases 
have  been  described  in  which  the  dizziness  was  so  severe  as  to  produce  a 
condition  resembhng  Meniere's  disease.  In  my  own  experience  I  have 
found  ringing  in  the  ear  to  be  the  most  distressing  and  common  sjaup- 
tom.  This  ringing  is  gencrall}^  continuous,  not  nmcli  modified  by  post- 
ure, and  not  of  ilic  pulsating  character,  but  rather  continuous  and  per- 
sistent. There  is  no  limitation  of  the  field  of  hearing — that  is  to  say, 
patients  can  hear  very  high  notes  and  YQvy  low  notes — but  in  a  considei-- 
able  number  of  neurasthenics  one  finds  a  slight  amount  of  deafness  of 
bone  conduction,  generalh',  however,  in  only  one  ear. 

Lari/ngeal  iSijiJiptonis. — Benno  Holz  reports  two  cases  of  aphonia  nerv- 
osa due  to  trauma  and  associated  with  paresis  of  the  abductors.  Paresis 
of  this  kind  is  rare,  but  does  occur.  Paralysis  of  the  dilators  of  the 
larynx,  however,  has  never  been  described  and  probabty  never  occurs. 
(H!  Burger.) 

^^a:^olllotor  DisfKrlxowes. — In  a  large  proportion  of  traumatic  neu- 
roses one  fiuds  evidences  of  vasomotor  weakness.  This  is  shown  in  the 
cold  hands  and  feet,  the  tendency  to  perspire  easily,  and  sensations  of 
heat  and  flushing.  There  is  also  in  many  cases  a  considerable  degree  of 
dermography.  On  drawing  a  dull-pointed  instrument  over  the  skin  of 
the  back  or  chest  a  broad  red  line  will  soon  develop,  which  lasts  some- 

*  Wilbvand  finds  often  some  CL  V  Field  in  neurasthenia,  bnt  most  others  disaejrpe 
(Konific,  Hochwardt,  Topolanski).  There  is,  however,  not  rarely  a  limitation  of  color- 
field,  especially  for  blue,     {yciir.  Ccntralbl.,  1893,  p.  5S4.) 


320  ^   SYSTEM  OF  LEGAL  MEDICINE. 

times  for  half  an  hoiu',  and  is  mneli  more  marked  tlian  in  normal  persons. 
This  vasomotor  distiu'bauce,  however,  is  often  found  in  healthy  people, 
and  may  depend  upon  other  things  than  a  nenrasthenic  state* 

There  sometimes  develops  a  local  cyanosis  of  the  extremities,  so  that 
the  fingers  or  the  toes  become  cold  and  white,  and  resemble  the  condition 
known  as  Raynaud's  disease.  A  few  cases  have  been  reported  in  which 
a  local  edematous  swelhng  developed  in  different  parts  of  the  bod}^  after 
tramna.  These  local  swellings  are  known  as  angionem-otic  edema.  They 
do  not  occur  necessaril}'-  near  the  part  injui-ed.  They  develop  rather 
suddenly  in  the  form  of  circumscribed  swellings,  which  are  usually 
somewhat  pale,  though  they  may  have  a  reddish  tinge,  and  they  do  not 
pit  on  pressure.  They  may  last  for  a  few  hom^s  or  daj^s  and  then 
disai3pear.t 

Traumatic  neurasthenics  are  often  liable  to  perspire  excessively.  This 
tendency  to  sweat  is,  however,  not  a  uniform  symptom,  and  at  times 
there  may  be  only  a  local  sweating.  Thus  the  patient  complains  of  an 
area  of  profuse  persj)iration  in  the  small  of  the  back,  or  on  the  legs,  or 
perhaps  only  on  one  side  of  the  body.  Urticaria  and  eruptions  of  a  sim- 
ilar character  sometimes  develop.  (Kriege.)  A  case  of  bloody  sweating 
has  been  reported  by  Ehrig.  It  occiuTcd  in  a  trapeze  performer,  who 
fell  and  struck  his  head.  The  local  bloody  sweat  took  place  on  the  head, 
and  was  accompanied  by  no  other  sign  of  sweating. 

The  bodily  temperature  has  been  found  at  times  subnormal,  while 
others  have  described  attacks  of  feverish  character.  In  my  own  experi- 
ence I  have  found  no  marked  or  important  changes  in  bodily  temperatui'e 
unless  there  was  an  hysterical  factor  in  the  case.  It  is  well  to  bear  in 
mind,  however,  the  experiments  of  Lehmann  {Cenfrcdhlatt  f.  INerrenheiU:, 
May,  1890),  who  found  that,  by  directing  attention  to  the  subject  of  bodily 
temperature,  indi^dduals  who  were  not  pre\4ously  hypnotized  could  raise 
the  temperature  as  much  as  half  a  degree  Fahrenheit. 

The  pulse  is  often  abnormally  frequent  in  the  traumatic  neuroses, 
ranging  from  90  to  100,  and  if  not  frequent  it  is  apt  to  be  irritable,  so 
that  slight  physical  exertion  and  shght  mental  excitement  accelerate  the 
beat  of  the  heart  greatly.  This  increased  pulse-frequency  and  abnormal 
irritability  of  the  heart  constitute  olijective  symptoms  which  may  be 
considered  to  have  much  j)ositive  value  in  diagnosis.  The  average  pulse 
in  fifty-nine  cases,  as  determined  by  Walton,  was  for  males  90.5,  and  for 
females  95.75.  This  rapidity  of  pulse  is  a  symptom  on  which  German 
writers  lay  much  stress,  and  Oppenheim  has  noted  some  cases  in  which 
as  a  result  of  persistent  rapid  heart-beat  some  dilatation  and  compensa- 
tory hypertrophy  of  the  heart  took  place.  The  increased  pulse-rate  when 
pressure  is  made  on  a  tender  point  has  ah-ead}'"  been  referred  to. 

The  condition  of  the  urine  in  traumatic  neurasthenics  is  also  some- 
what characteristic.  It  is  apt  to  vary  much  in  quantity,  sometimes  the 
patients  suffering  from  poljoiria  and  again  from  a  rather  condensed 
Tirine.     There  is  at  times  an  irritable  bladder  and  tendency  to  frequent 

*  Ludwig  Man  {Berlin  KUn.TVochenschr.,  July,  1893)  finds  a  lessened  electrical  re- 
sistance of  the  head  in  tranmatic  neuroses.  He  uses  small  electrodes  and  weak  cur- 
rents (3  elements).  He  puts  one  electrode  on  the  neck,  the  other  on  the  forehead.  He 
finds  the  normal  resistance  4000  to  6000  ohms ;  in  neuroses,  1500  to  2500.  Eulenberg, 
using  larger  electrodes,  6x12  ctm.  and  10  elements,  finds  the  normal  only  1200  to  1600. 

t  Guinon  reports  a  ease  of  blue  edema  with  anaesthesia  after  a  fall.     (Op.  cit.) 


TUE   TRAUMATIC  NEUROSES.  321 

micturition.  The  urine  in  most  eases  presents  a  relative  excess  of  plios- 
phates,  and  the  earthy  phosphates  in  jjarticular  are  increased  disprcjpor- 
tionately. 

Methods  of  Examination  and  Diagnosis. — I  have  not  space  to  go 
over  in  detail  all  the  methods  wldch  are  reqnired  in  a  thorough  exami- 
nation of  a  case  of  traumatic  neurosis  or  traumatic  neurasthenia.  The 
details  of  these  methods  are  given  in  text-books  on  nervous  diseases.  It 
will  be  sufficient  for  my  purpose  now  to  give  simply  an  outline  of  the 
general  plan  to  be  pui'sued,  and  then  to  call  attention  to  certain  special 
methods  which  are  of  importance  in  the  determiuation  of  objective  symp- 
toms and  in  the  detection  of  simulation.  The  physician  wlio  is  examin- 
ing a  patient  should  proceed  in  a  certain  regular  and  systematic  way. 
An  outline  of  the  plan  to  be  followed  is  given  in  the  accompanying 
scheme : 

1.  Preliminary  facts :  name,  age,  sex,  condition,  nationality,  occupa- 
tion. 

2.  Family  history. 

3.  Personal  history. 

4.  History  and  causes  of  present  disease. 

5.  Physiognomy  of  case. 

General  appearance,  nutrition,  abnormalities,  gait,  etc. 

6.  Disorders,  if  any,  outside  of  nervous  sphere. 

Digestion,  heart,  lungs. 

Temperature,  respiration,  pulse,  urine. 

7.  Psychical  sphere :  mental  condition ;  sleep,  etc. 

8.  Motor  sphere  :  paralysis ;  tremor ;  abnormal  movements ;  atrophy ; 
-electrical  and  mechanical  reactions  of  muscle  and  nerve ;  speech. 

9.  Sensory  sphere.  General  sensations :  vertigo  ;  pain ;  paraesthesia. 
Special  sensations :  tactile,  temperature,  pain,  muscular  (ataxia) ;  vision  j 
hearing,  taste,  smell. 

10.  Reflexes  superficial,  deep,  organic. 

11.  Trophic,  vasomotor,  and  secretory  disturbances. 

The  examiner  should  bear  in  mind  the  importance  of  weighing 
all  the  evidence  as  impartially  as  possible ;  of  allowing  only  the  proper 
weight  to  the  statements  of  the  patient ;  of  securing  evidences  of  organic 
disease,  evidences  of  conditions  which  the  patient  cannot  simulate ;  and 
he  should  bear  in  mind  also  that  while  the  patient  may  be  perfectly 
sincere  he  has  so  much  at  stake  that  he  will  often  exaggerate.  It  is 
well  to  secure  a  careful  history  of  aU  the  details  of  the  accident,  and 
to  have  the  history  corroborated  from  several  sources.  The  facts  \vith 
regard  to  the  condition  of  the  patient  subsequent  to  the  injmy  should 
also  be  gathered  with  the  greatest  care.  The  physician  must  in  all  cases 
assume  an  attitude  which  is  not  sympathetic  but  critical ;  he  must,  even, 
perhaps,  at  the  expense  of  a  certain  apparent  unkindness,  investigate 
every  statement  and  every  phenomenon  that  is  presented  in  connection 
with  the  case.  He  should  also  take  especial  pains  to  inquire  into  the 
previous  health  of  the  patient.  It  has  been  found  by  Walton  that  in 
seventeen  out  of  a  hundred  cases  there  was  some  nervous  or  oi-ganic 
disease  before  the  injury  occurred,  and  investigations  by  other  authorities 
have  led  to  similar  results.  Having  secured  a  full  and  complete  history 
of  the  case,  the  j)hysician  proceeds  to  the  direct  physical  examination  of 
his  patient.     For  the  pm'pose  of  carrying  out  such  an  examinatiou  in  all 


222  ^  SYSTEM  OF  LEGAL  MEDICINE. 

its  details  a  considerable  immber  of  appliances  are  necessary  in  many- 
cases.  The  following-  list  may  be  perhaps  of  some  use  to  those  who  de- 
sire to  equip  themselves  for  this  kind  of  work :  a  stethoscope ;  appliances 
for  examining  the  mine ;  a  galvanic  and  faradic  batter}^  with  milliam- 
peremeter,  sponge  electrodes,  and  a  wire  brush  with  interrupting-handle ; 
a  dynamometer,  esthesiometer,  and  ophthalmoscope ;  a  perimeter ;  a  Gal- 
ton's  whistle;  a  tuning-fork;  a  percussion-hammer;  and  materials  for 
testing  the  senses  of  smell  and  taste.  In  addition  to  these  one  may 
sometimes  have  use  for  a  sphygmograph,  and  in  my  own  work  I  am  ac- 
customed also  to  use  special  dynamometers  for  the  legs  and  extensor 
muscles  of  the  arms ;  a  concealed  needle  for  testing  the  sense  of  pain ; 
metal  tubes  one  centimeter  in  diameter,  which  are  used  in  testing  the 
cold  and  heat  sense  according  to  Goldscheider's  method;  weights  for 
testing  the  muscular  sense ;  a  bass-viol  string  for  testing  low  notes ;  an 
instrument  for  testing  ataxia  and  measuring  its  degree ;  also  an  instru- 
ment for  testing  slight  degrees  of  tremor. 

Anatomical. — Preliminary  to  a  detailed  description  of  methods  of 
examination,  I  have  thought  that  it  would  be  helpful  to  the  reader  to  in- 
sert some  anatomical  diagrams  which  could  be  referred  to  in  the  course 
of  an  examination  or  in  preparation  for  it.  Fig.  41  illustrates  the  com- 
parative size  and  relations  of  the  brain  and  spinal  cord  as  they  appear 
when  removed  together  from  the  body.  Fig.  42  shows  the  relations  of  the 
brain  and  cord  in  their  normal  position  in  the  body.  Fig.  43  shows  the 
points  of  exit  of  the  cutaneous  branches  of  the  spinal  nerves.  Fig.  44 
shows  the  positions  of  the  spinous  processes  of  the  vertebrae  (indicated 
by  the  squares),  the  point  of  exit  of  the  spinal  nerves  (indicated  by  the 
horizontal  lines),  and  the  relation  of  the  points  of  origin  of  the  spinal 
nerve  roots  (indicated  by  the  dotted  hues)  to  the  spinous  processes. 
Thus  the  third  lumbar  nerve  is  seen  to  originate  at  a  point  between  the 
tenth  and  eleventh  dorsal  spines.  Figs.  45  to  52  show  the  normal  dis- 
tribution of  the  sensory  nerves,  and  are  of  help  in  mapping  out  the  dis- 
tribution of  anesthesia,  and  in  determining  whether  this  corresponds  to 
the  area  of  any  given  nerve  or  nerves.  Such  facts  are  of  importance 
both  in  localizing  lesions  and  in  questions  of  diagnosis  between  organic 
and  hysterical  troubles.     (See  Traumatic  Hysteria.) 

It  is  customary,  before  proceeding  to  test  the  condition  of  the  nerv- 
ous system,  to  examine  the  other  organs,  and  some  points  may  be  given 
here  with  regard  to  this  matter. 

Tests  of  Heart  Action. — I  have  already  referred  to  the  fact  that  the 
heart-beat  is  sometimes  abnormally  rapid,  and  to  the  fact  that  pressm-e 
upon  a  tender  point,  particularly  one  near  the  spine,  wlQ  produce  an  ac- 
celeration of  the  pulse-rate.  According  to  Mannkopf  such  pressure  will 
raise  the  pulse  from  84  to  92  or  from  100  to  120,  and  this  acceleration 
lasts  for  two  or  more  minutes ;  the  pulse  also  gets  smaller.  This  test  is 
known  as  the  neuralgic  cardiac  reaction.  In  examining  the  pulse  it  is  im- 
portant to  feel  the  two  radial  arteries  or  the  two  carotids  or  the  two 
femorals  at  the  same  time,  the  physician  placing  a  finger  of  each  hand 
upon  the  two  arteries.  In  this  way  he  can  determine  whether  the  pulse 
on  the  two  sides  is  synchronous,  and  may  possibly  detect  the  presence  of 
an  aneurism.  The  sphygmograph  will  in  my  experience  usually  give  a 
curve  of  low  tension  and  one  that  is  somewhat  characteristic  of  the  neu- 
rasthenic heart.     I  have  taken  the  tracings  of  twelve  typical  cases  of 


324 


A   SYSTEM  OF  LEGAL  MEDICLNE. 


neurasthenia  and  superimposed  tliem,  producing  as  a  result  a  sphygmo- 
gram,  wliich.  may  Le  considered  to  represent  the  neurasthenic  type. 

The  characters  of  the  urine  in  traumatic  neurasthenia  I  have  referred 
to  already  under  the  head  of  Symptoms.     Tests  for  phosphates,  both 

earthy  and  alkaline,  for  al- 
bumin, casts,  sugar,  uric 
acid,  and  indiean  should  be 
made. 

Tests  for  Motor  Nerves  and 
the  Muscles. — The  existence 
of  tremor  or  spasm  is  of 
course  easily  determined.  It 
is  very  important,  however, 
to  study  carefully  the  char- 
acter of  these  disturbances. 
The  tremor  is  usually  of  a 
fine  and  vibratory  character, 
the  rate  of  vibration  being 
about  ten  per  second.  It  is 
best  produced  by  making  the 
patient  extend  the  hand  and 
spread  out  the  fingers.  It 
does  not  increase  on  volun- 
tary motion,  and  is  ^^ery  slight 
when  the  patient's  extremi- 
ties are  relaxed  and  qidet. 
The  head  is  not  affected,  and 
when  there  do  oceiu"  some- 
oscillatory  or  nodding  mo- 
tions of  the  head  it  is  sig- 
nificant of  some  hysterical 
condition  or  some  serious 
neurosis.  Slight  muscular 
twitchings  of  the  face  and 
extremities  are  not  at  all  rare 
symptoms,  and  are  of  some 
importance  as  indicating 
motor  irritaliility.  When  a 
paralysis  exists  it  is  of  ex- 
treme importance  to  deter- 
mine whether  it  be  of  a  func- 
tional or  oi'ganic  character. 
The  points  for  determining 
this  are  given  in  detail  also 
in  standard  works  on  neu- 
rology, and  they  cannot  be 
entered  upon  fully  here.  It 
is  important,  however,  to  bear 
in  mind  that  in  functional 
palsies  there  is  little  or  no  atrophy,  and  that  the  same  fact  applies  to 
palsies  due  to  brain  disease,  except  in  children.  A  certain  amount  of 
wasting  occurs  in  the  limbs  from  disuse,  but  in  my  own  experience  this. 


Fig.  43,  showing  the  points  of  exit  of  the  cutaneous 
branches  of  the  spinal  nerves.   (Van  Gehuchten.) 


Fjg.  44,  showing  the  position  of  the  spinous  processes  vindicated  bv  the  squares),  the  points 
ot  exit  ot  the  spinal  nerves  (indicated  by  the  continuous  lines),  and  the  points  of  origin  Of  each 
nerve  (indicated  by  the  dotted  lines).  Thus  the  tifth  lumbar  nerve  originates  at  a  point  be- 
tween the  eleventh  and  twelfth  dorsal  spines.  Drawn  from  a  photograph  of  a  man  on  wh^ 
these  points  had  been  mapped  out. 

325 


rhom 


326  ^  SYSTEM   OF  LEGAL   MEDICINE. 

rarely  exceeds  liaK  an  inch  for  the  leg,  and  hardly  as  much  for  the  arm. 
(See  p.  316.)  The  most  important  means  of  determining  the  organic  char- 
acter of  a  paralysis  is  by  the  nse  of  electricity.  I  feel  very  confident  that 
I  am  correct  in  stating  that  degeneration  reactions  are  never  f  onnd  when 
the  paralysis  is  of  a  functional  type,  and  that  they  do  not  occur  in  hys- 
teria uncomplicated  with  organic  disease.  By  a  "  degeneration  reaction  " 
I  mean  a  diminution  in  the  contractility  of  the  muscle  to  the  faradic  cur- 
rent, with  a  peculiar  sluggishness  of  reaction  when  the  current  is  passed 
through  the  muscle.  Sometimes  there  are  changes  in  the  relative  excita- 
bility to  the  two  poles,  so  that  the  positive  pole  on  closing  the  current 
gives  a  stronger  reaction  than  the  negative ;  and  sometimes  the  contrac- 
tion is  not  only  sluggish  but  diffuses  over  the  whole  body  of  the  muscle. 
'There  are,  I  believe,  some  electrical  changes  which  to  a  certain  extent  are 
■characteristic  of  a  neurasthenic  state — that  is,  of  a  state  of  irritability  and 
weakness  of  the  nervous  centers.  I  think,  however,  we  cannot  yet  posi- 
tively formulate  what  these  are.  Rumpf  has  laid  down  three  tests  for  the 
traumatic  neuroses  :  first,  pressure  on  painful  points,  giving  rise  to  accel- 
eration of  the  pulse  (Mannkopf's  symptom) ;  second,  a  quantitative  reduc- 
tion in  galvanic  irritability  of  motor  nerves ;  thu'd,  a  fibrillary  contrac- 
tion of  the  muscles,  which  lasts  sometimes  after  the  current  has  passed 
through  them,  and  which  extends  into  adjoining  muscular  groups.  This 
he  calls  the  traumatic  reaction.  The  second  symptom  occurs  only  late  in 
the  disease,  that  is  to  say,  one  or  two  years  after  its  inception.  He  finds, 
for  example,  that  in  the  normal  ulnar  and  peroneal  nerve  the  Ka  C  C 
(negative  pole  closure-contraction)  is  produced  by  ^  to  2  milliamperes, 
in  a  traumatic  neurosis  by  4  to  10  milliamperes ;  the  normal  Ka  C  Te 
(negative  pole  closure-tetanus)  is  produced  by  4  to  11  milliamperes,  that 
in  the  traumatic  neurosis  by  20  to  25  milliamperes. 

There  is  in  the  traumatic  neuroses  an  abnormal  degree  of  muscular 
weakness ;  the  patients  tire  easily  and  are  incapable  of  theii'  ordinary 
amount  of  physical  work.  This  symptom,  of  course,  is  easily  simulated, 
and  is  one  that  is  almost  always  complained  of  by  malingerers.  A  test 
for  the  genuineness  of  this  symptom  has  been  described  by  Wichmann ; 
it  consists  in  sending  the  patient  to  an  institute  where  appliances  exist 
for  measuring  the  muscular  strength  of  the  different  groups,  and  oblig- 
ing him  to  go  through  various  exercises.  He  is  watched  while  this  is 
done,  and  the  records  that  he  is  able  to  make  are  compared  with  the 
normal.  The  observation  of  the  patient  at  this  time  is  also  often  help- 
ful ;  for  a  geniune  neurasthenic  who  wants  to  get  well  will  do  his  best 
at  the  work  laid  down  for  him,  while  the  simulator  is  constantly  groan- 
ing and  complaining  at  the  distress  that  every  effort  causes  him. 

Tests  for  Sensory  Symptoms. — The  subjective  complaints  of  pain  and 
of  tenderness  are  always  very  great  and  prominent  symptoms.  The 
method  of  testing  it  by  the  "  traumatic  cardiac  reaction,"  or  Mannkopf's 
symptom,  has  already  been  described.  Pain  along  the  back  occurs  in 
about  two  thirds  of  the  cases,  and  is  always  a  matter  of  especial  concern 
to  the  patient.  The  physician  in  examining  the  patient  finds  tender  spots 
along  the  spine,  and  these  spots  will  sometimes  vary  even  during  the 
single  examination.  This  variability  of  tenderness  used  to  be  considered 
a  sign  of  malingering,  but  I  do  not  believe  it  always  is,  since  it  will  be 
noted  in  neurasthenics  who  have  no  object  for  deceit.  However,  very 
gross  and  persistent  changes  in  the  location  of  pain  may  be  considered 


THE  TEALMATW  XECIiOSES. 


327 


328 


A   SYSTEM  OF  LEGAL  MEDICINE. 


suspicious ;  so  also  is  tlie  absolute  aud  uuif orm  localization  of  pain- 
ful spots  on  the  same  vertebra  at  different  examinations.  In  testing  for 
painful  spots  the  physician  should,  however,  always  make  it  a  point  to 
distract  the  patient's  attention,  for  if  he  finds  that  a  place  which  was 
asserted  to  be  extremely  sensitive  on  pressure  can  be  vigorously  punched 
when  the  j)atient's  attention  is  distracted,  it  is  usually  an  evidence  of 
either  mahngering  or  some  very  hysterical  state.  The  tenderness  of  the 
skin  and  of  the  parts  beneath  should  be  separately  examined.  Anesthe- 
sia of  the  skin  in  its  different  degrees  should  be  tested  by  means  of  the 
aesthesiometer,  by  which  tactile  and  pain  senses  are  determined,  and  with 
hot  and  cold  tubes,  by  which  the  temperature  sense  is  determined.     In 


Fig.   4T. 


Fig.  48. 


Fig.  49. 


ptron-.prirf. 


Fig.  51. 

testing  for  anaesthesia  to  pain  (analgesia)  it  is  not  sufficient  to  use  simple 
pricking-instruments,  but  the  strong  faradic  brush  should  be  emploj^ed. 
It  is  sometimes  a  good  plan  also  to  use  a  large  wire  brush,  one  part  of 
which  is  laid  over  an  alleged  anaesthetic  area,  the  other  extending  over 
the  non-antesthetic  area.  The  current  being  turned  on,  the  brush  can  be 
tilted  so  that  at  one  time  it  touches  the  anaesthetic  part  and  at  another 
time  not,  and  in  this  way  malingering  can  sometimes  be  detected.  In 
testing  the  sense  of  cold  and  heat  Go]d.scheider's  method  may  be  at  times 
employed  to  advantage,  and  objective  symptoms  can  in  this  way  be  de- 
termined.    The  test  of  the  cold  sense  is  made  with  metal  cylinders  at 


TUE   TRAUMATW  NEUROSES.  329 

from  59°  to  63°  F.,  that  of  the  hot  sense  witli  cylinders  at  from  113^  to 
120°  F.,  the  patient's  eyes  being-  closed.  Tiring-  and  cooling  of  the  skin 
aifect  tlie  results.  The  latter  will  correspond  most  closely  with  (iold- 
scheider's  noi-mal  tallies  when  the  cutaneous  tem})erature  in  the  first  in- 
terosseous space  of  tlie  hand  or  foot  is  from  85°  to  86°  F.  The  examina- 
tion begins  with  tlie  test  of  the  cold  sense,  a  maximal  point  being  tested. 
If  the  patient  feels  no  temx)erature,  but  merely  a  sensation  of  pi-essure, 
then  there  is  anaesthesia  of  the  cold  sense,  whose  limit  and  intensity  must 
be  determined.  The  intensity  is  tested  by  maximal  temperature  irrita- 
tions. For  the  cold  sense  a  temperature  of  the  metal  cylinders  of  50°  F. 
suffices.  But  when  the  cylinder  placed  on  the  maximal  point  produces 
a  sensation  of  temperature,  the  question  is  whether  it  is  normal  or  weaker. 
Therefore  the  mininuil  point  is  next  tested,  aud  if  this  is  likewise  given 
correctly  the  sense  of  temperature  is  normal.  But  if  disturbance  is 
found — diminution  (hypa^stliesia),  hypertx'sthesia  being  very  rare  accord- 
ing to  Goldscheider — its  degree  must  be  ascei'tained  l)y  comi)arison  with 
symmetrical  points  or  with  equivalent  other  points  of  the  table.* 

Visual  Teds. — It  is  of  course  best  in  many  cases  to  have  the  eye  care- 
fully examined  by  a  competent  ophthalmologist ;  the  neurologist,  how- 
ever, in  particular  determines  the  condition  of  the  muscles  and  of  the 
visual  field  and  also  the  visual  acuity.  As  ah'eady  stated,  there  is  often 
a  consideral^le  degree  of  weakness  of  the  adductor  muscles.  This  is  tested 
with  prisms  and  colored  glasses,  and  by  means  of  them  often  the  efforts 
of  the  patient  to  deceive  may  be  detected,  particularly  if  this  patient  feigns 
serious  disturbances  of  A^sion,  such  as  diplopia  or  amblyopia.  The  de- 
termination of  the  visual  field  is  made  by  means  of  the  perimeter  accord- 
ing to  the  methods  ordinarily  described  in  the  text-books.  In  my  ex- 
perience there  is  no  contraction  of  the  visual  field  in  ordinary  cases  of 
traumatic  neurasthenia ;  but  there  is,  as  I  have  already  stated,  some  de- 
gree of  retinal  hypa?stliesia  in  the  peripheral  portion,  so  that  objects  are 
not  seen  as  distinctly  or  as  long  in  the  outer  limits  of  the  visual  field.  I 
can  confirm  the  statements  of  Konig  and  Wilbrand  aud  Forster  with 
regard  to  the  existence  of  the  shifting-type  in  traumatic  neuroses,  as  de- 
scribed above.  (See  Fig.  40.)  It  is  not  present,  however,  in  aU  cases.  In 
testing  for  the  field  of  vision  the  examiner  should  use  a  perimeter  for  near 
objects,  and  then  should  confirm  his  findings  by  testing  ^xiih.  objects  at  a 
considerable  distance.  In  this  way  attempts  at  simulation  may  be  de- 
tected. 

With  regard  to  the  other  special  senses  I  have  already  said  sufficient 
under  the  head  of  S3'mptoms. 

The  tesfiiu/  of  tlie  rejiexcs  and  of  the  muscular  ii-ritability  is  a  matter 
of  much  importance.  As  a  rule,  the  deep  reflexes  are  exaggerated ;  when 
they  are  not,  I  have  generally  found  that  there  was  either  a  history  of 
alcoholism  or  some  infectious  disease.  The  skin-reflexes  also  are  apt  to 
be  exaggerated,  and  the  })eculiar  enlarged  area  over  whicli  the  cremasteric 
reflex  can  be  elicited  has  been  already  described.  (See  Figs. 34,  35,  and  30.) 
In  intercostal  neuralgia  it  is  stated  by  Seeligmiiller  that  the  abdominal 
reflex  on  the  affected  side  is  exaggerated. 

In  testing  for  ataxia  one  should  try  to  detennine  the  power  of  the 

*  Goldselioidei-'s  table  and  figures  are  published  in  the  Archiv.  fiir  rsychiatrie, 
vol.  xviii.,  1887. 


330  ^   SYSTi:2I  OF  LEGAL  MEDICIXE. 

patient  to  stand  steadily  T\dtli  the  eves  open  and  then  ^vitli  the  eyes  closed, 
the  heels  and  toes  being  placed  together.  The  patient  should  also  be 
tested  as  to  his  power  to  place  the  extremities  in  different  positions, 
touching  different  parts  of  the  body  with  the  eyes  closed,  and  as  to  his 
knowledge  of  the  position  of  his  limbs  when  the  eyes  are  closed,  and  also 
as  to  his  ability  to  determine  different  weights. 

The  question  now  comes  finally  as  to  whether  there  are  any  single 
objective  sjnnptoms  by  means  of  which  we  can  say  that  the  patient  has 
a  traumatic  neurasthenia.  My  own  belief  is  that  there  are  objective 
sjTuptoms  whose  existence  shows  that  the  patient  is  not  simulating,  but 
has  some  real  morbid  condition.  There  is,  however,  no  single  objective 
s^nnptom  upon  wliich  we  can  alone  rely.*  The  aggregation  of  all  the 
objective  spnptoms  does  not  prove  that  the  patient  has  a  traumatic  neu- 
rasthenia, but  does  prove  that  he  has  some  morbid  condition  whose  exact 
nature  must  be  determined  by  the  history  of  the  case.  Practically  the 
object  of  the  examinations  in  most  cases  is  to  determine,  first,  whether 
the  patient  is  simulating,  and  next  whether  he  has  organic  or  functional 
disease,  and  finally,  if  he  has  only  functional  disease,  what  the  exact 
nature  of  that  trouble  is.  Now,  as  to  the  last  point,  we  can  say  that  it 
is  traumatic  nem-asthenia.  We  find  that  the  patient  suffers  from  the  pe- 
cuLiar  psychical  anomalies  referred  to,  the  subjective  sensor}^  disturbances, 
the  insomnia  and  cerebral  paraesthesia,  and  such  objective  spnptoms  as 
muscular  weakness  and  irritability,  tremor,  static  ataxia,  exaggerated 
reflexes,  accelerated  pulse  and  cardiac  iiTitability,  vasomotor  disturbances, 
disturbances  of  the  ^dsual  field  and  am-al  field.  I  do  not  mean  to  say 
that  it  is  necessary  that  the  patient  have  all  of  these  sjTnptoms,  and  it 
must  be  left  to  the  experience  and  judgment  of  the  physician  to  deter- 
mine the  weight  to  be  placed  upon  them. 

Pathology  and  Pathological  Anatomy. — There  is  not  very  much 
use,  in  my  opinion,  of  speculating  as  to  the  pathology  of  the  morbid 
state  known  as  traumatic  neurasthenia.  It  appears  to  be  a  condition 
in  which  there  is  an  excessive  weakness  and  irritability  of  the  cells  of  the 
central  nervous  system  ;  those  groups  of  cells  controlling  and  regulating 
the  cu-culation  of  blood — that  is  to  say,  the  vasomotor  system — being 
particularly  affected.  There  have  been  up  to  the  present  time  but  few 
cases  of  post-mortem  examinations  made  in  traumatic  neuroses.  In  1875 
Willigk  reported  the  case  of  a  boy  of  nine  who  had  a  fall  and  received  a 
severe  injury  upon  the  head.  He  developed  some  s^Tuptoms  of  a  neuras- 
thenic and  iij^sterical  character.  He  died,  and  the  post-mortem  showed 
some  softening  in  the  pons.  The  case  is  e^'idently  not  one  in  point, 
though  often  quoted  under  the  head  of  the  pathology  of  traimiatic  neu- 
roses. Oppenheim  (23)  in  1888  reported  an  autopsy  upon  one  case.  He 
found  no  lesion,  but  there  was  no  microscopical  examination  made.  In 
1889  Sperling  and  Kronthal  reported  a  case  of  a  man  who  at  the  age  of 
forty-two  received  a  slight  injury  in  a  raih-oad  collision,  followed  at  once 
by  sjTnptoms  of  traumatic  neurasthenia.  The  man  gave  no  history  of 
syphihs  or  alcoholism.  The  history,  however,  of  his  s^Tuptoms  was  im- 
perfect, and  on  post-mortem  they  found  a  high  degree  of  arterial  sclerosis, 
especially  of  the  brain  and  cord,  and  a  peculiar  degeneration  of  the  sym- 

*  The  contraction  of  visual  field,  rapid  pulse,  anaesthesia  or  hypa?sthesia,  and  psy- 
chic anomalies  are  characteristic  and  objective  symptoms  according  to  Oppenheim. 


THE   TRAUMATIC  NEUROSES.  331 

pathetic  system.  Small  insular  patches  of  sclerosis  of  slight  degree  were 
fonud  in  all  parts  of  the  white  matter  of  the  cord,  with  degeneration  of 
ganglion  cells  in  a  small  area  in  the  lower  dorsal  region,  including 
Clarke's  columns.  There  was  a  small  hemorrhage  in  the  middle  of  the 
dorsal  cord.  Bernhai-dt  and  Kronthal  re})ort  a  case  of  a  man  aged 
thirty-three  who  was  struck  in  the  epigastrium  by  a  horse's  hoof.  He 
suffered  from  a  severe  degree  of  hystero-neurasthenia  for  three  years, 
and  finally  hung  himself.  The  cord  only  was  examined.  Some  slight 
arterial  thickening  and  numerous  patches  of  sclerosis  were  discovered  in 
the  white  matter  of  the  spinal  cord.  The  patient  had  passed  blood  and 
vomited  it,  but  there  was  no  lesion  found  in  the  stomach  or  intestines. 
Schmauss  has  reported  the  case  of  a  man  aged  twenty-nine  who  fell  from 
a  ladder  and  gradually  developed  the  symptoms  of  a  combined  systemic 
degeneration  of  the  spinal  cord.  There  was,  however,  an  imperfect  his- 
tory of  the  case.  Schmauss  also  rej^orts  the  results  of  some  experiments 
upon  animals,  which  do  not  throw  very  much  light  on  the  pathology  of 
the  tramnatic  neurosis.  Friedmann  in  1890  reported  two  cases  of  head 
injury,  occurring  in  a  man  of  twenty-seven  and  a  woman  of  thirty.  The 
injuries  were  occasioned  by  falls,  and  were  followed  by  sjmiptoms  of 
meningeal  irritation,  with  paroxysms  of  excitability.  In  the  first  case 
there  was  a  paralysis  of  one  of  the  cranial  nerves.  After  death  no  gross 
lesion  was  discovered  in  either  case,  although  it  had  been  supposed  there 
was  some  pachymeningitis.  The  microscopical  examination  was  made 
in  one  case  only.  The  blood-vessels  were  found  to  be  distended  and 
sacculated  in  places,  and  filled  with  blood.  The  perivascular  spaces  were 
dilated,  and  there  were  blood  pigment  and  round  cells  in  them.  There 
was  also  found  a  hyaline  degeneration  of  the  walls  of  the  blood-vessels — 
in  fact,  the  record  is  suggestive  of  a  syphilitic  process. 


THE   GRAVE   TRATOIATIC  NEUROSIS. 

In  some  rare  cases  severe  traumatism  may  be  followed  by  the  produc- 
tion of  a  series  of  symptoms  which  partake  partly  of  the  natiu-e  of  neuras- 
thenic or  hysterical  disorder  and  partly  of  the  natiu-e  of  organic  disease. 
The  neurasthenic  and  hysterical  symptoms  are  much  like  those  observed 
in  the  traumatic  neuroses  of  other  types.  The  additional  symptoms, 
which  suggest  the  existence  of  actual  organic  lesions,  are  such  as  have 
been  observed  in  the  condition  known  as  disseminated  sclerosis  of  the 
brain  and  cord.  The  exact  nature  of  these  cases  has  yet  to  be  definitely 
settled.  There  is  a  steady  and  even  gradation  between  cases  of  severe 
traumatic  neurasthenia,  traumatic  hysteria,  and  the  gi'ave  traumatic 
neurosis  sclerosis;  just  as  it  is  often  exceedingly  difficult  to  draw  a 
shar])  line  between  the  very  exaggerated  type  of  traumatic  hysteria  and 
a  case  of  what  seems  to  be  a  disseminated  sclerosis.  These  cases,  how- 
ever, are  extremely  rare,  at  least  in  this  country.  In  my  own  expe- 
rience I  have  seen  but  a  few.  The  causes  of  the  development  of  this 
form  of  ti'ouljle  are  traumatisms  which  are  particularly  severe  ami 
in  which  the  head  has  been  also  injured.  I  do  not  believe  that  such  a 
disorder  can  be  produced  by  psychical  shock  alone.  The  trouble  seems 
to  affect  men  oftener  than  women,  just  as  is  the  case  with  major  hysteria, 
and  it  occiu-s  usually  in  persons  who  have  reached  the  thii-d  or  fourth 


332  ^   SYSTEM  OF  LEGAL  MEDICINE. 

decades  of  life.  The  symptoms  develop  hi  some  cases  very  rapidly  after 
the  injiny  is  received.  The  patient  suffers  from  headache  and  vertigo ; 
meiitally  he  is  depressed,  irritable,  hypochondriacal,  although  this  mental 
state  I  do  not  find  always  to  exist.  Sometimes  the  patient  is  rather 
hopeful,  but  is  at  the  same  time  emotional  and  perhaps  a  little  childish. 
The  mental  power  in  each  case,  is  lessened.  Either  soon  after  the  at- 
tack or  some  months  later  he  develops  tremors  of  the  extremities  and 
tongue,  speech  becoming  somewhat  thick  or  syllabic.  Nystagmus  may 
be  present.  The  tremor  is  coarse  and  jevkj  in  character,  large  in  range, 
and  increases  on  voluntary  effort ;  in  other  words,  it  resembles  that  ob- 
served in  multiple  sclerosis  and  also  in  some  forms  of  hysteria  major. 
There  is  exaggeration  of  reflexes,  as  a  rule  ;  no  paralyses,  however,  occur. 
There  may  be  some  incoordination  and  some  cutaneous  anaesthesia,  which 
is  usually  not  limited  to  one  side  of  the  body. 

The  visual  fields  are  limited,  and  occasionally  there  is  optic  atrophy. 
There  is  also  at  times  limitation  of  the  auditory  field  and  disturbance  of 
the  sense  of  taste.  Sometimes  there  is  lack  of  control  over  the  bladder, 
and  the  patient  may  suffer  from  pain  and  stiffness  in  the  back.  These 
symptoms  progress  until  they  reach  the  stage  which  practically  incapac- 
itates the  patient  from  work,  although  he  is  not  alwa3''S  bedridden,  and 
finally  he  presents  the  picture  very  much  of  a  case  of  disseminated  scle- 
rosis. The  organic  changes  underlying  the  trouble  are  those  of  minute 
spots  of  sclerosis  in  the  brain  and  cord.  My  own  opinion  is  that  at 
present  we  must  consider  these  cases  as  belonging  to  the  type  of  multiple 
sclerosis  described  in  systematic  works.  It  will  be  found  that  very  few 
cases  of  this  disorder  occur  which  are  not  preceded  either  by  an  infective 
fever  or  by  some  severe  trauma.  A  good  illustration  of  a  traumatic 
neurosis  of  this  type  is  the  following.  The  history  of  the  case  has  been 
kindly  prepared  for  me  by  Dr.  Joseph  Collins,  under  whose  care  the 
patient  is. 

F.  M.,  aged  fifty-seven ;  born  in  Ireland ;  laborer. 

Family  History. — No  phthisis,  rheumatism,  insanity,  epilepsy,  nor 
hereditary  predisposition. 

Previous  Illness. — With  exception  of  a  fever  when  a  young  man,  has 
never  been  ill;  has  always  been  as  sound  as  a  "paving-stone." 

Hygiene  and  Habits.— Has  been  twice  married,  childi'eu  healthy.  Has 
never  had  venereal  disease.     Alcoholic  in  a  moderate  way  aU  his  life. 

Present  Illness. — Two  years  ago,  while  riding  on  a  load  of  hay,  fell, 
struck  on  head,  was  carried  to  St.  Vincent's  Hospital,  remained  uncon- 
scious for  two  days,  and  when  he  recovered  consciousness  was  in  a 
dazed  condition  for  a  day  or  two  longer.  He  remained  in  the  hospital 
for  two  weeks.  When  he  left  there  he  was  weak  and  ''  shaky."  He  was 
unable  to  go  to  his  ordinary  occupation,  but  got  light  work  about  a  stable. 
In  less  than  a  month  after  leaving  the  hospital  he  noticed  that  his  hands 
were  very  unsteady  and  that  it  was  necessary  to  use  both  of  them  to  carry 
a  cup  or  glass  to  the  mouth.  The  shaking  and  weakness  were  more  in 
the  left  hand  and  arm  than  in  the  right.  At  this  time  he  noticed  also 
that  his  hearing  was  gradually  becoming  impaired,  and  this  impairment 
steadily  became  worse.  He  remarked  also  (one  month  after  the  injury) 
that  there  was  some  impediment  in  speech  ;  the  words  did  not  come  regu- 
larly, as  before.  These  symptoms,  particularly  the  shaking  of  the  hands 
and  the  trembling  of  the  voice,  he  noticed  were  considerably  increased  by 


TUE   TIUUMATIC  NEUROSES.  ?i^?, 

excitement,  and  less  so  by  fatigue.  At  tliis  time  very  little  continuous 
etfort  cans('d  fati^'ue.  Always  in  cold  weather  lie  felt  Avorse.  Altliough 
the  appetite  remained  good,  and  bowels  and  l)ladder  regular,  he  could  not 
gain  strength.  He  did  not  suifer  headache,  dizziness,  or  pains.  He  has 
noticed  that  it  is  very  difficult  to  make  him  perspire.  AVhen  he  takes 
alcohol  (which  he  does  but  rarely,  on  account  Of  being  in  hospital)  he 
feels  better,  and  the  tremor  is  not  so  marked. 

Exammation — Appearance. — Poorly  nourished.  Face  always  the  seat 
of  a  passive,  dark,  sluggish  flush.     Countenance  not  expressive. 

station  and  Gait. — Both  good.     Does  not  have  tendency  to  fall. 

Tremor. — Slow,  rate  24  to  27  in  ten  seconds,  increased  by  fatigue, 
such  as  from  holding  his  hands  out  for  a  minute.  Amplitude  extensive, 
and  becoming  more  so  on  fatigue  and  on  voluntary  effort.  Both  upper 
extremities  are  affected,  left  side  considerably  more  than  right.  In  lower 
extremities  mostly  in  left.  Moderate  tremor  of  head,  winch  does  not 
reach  nodding. 

Reflexes — Knee-jerls. — Both  lively.  Left  very  moderately  increased. 
Slight  ankle-clonus  of  left  ankle. 

Eyes. — No  nystagmus,  either  on  movement  or  rest.  Slight  arcus 
senilis.  Flecks  of  degenerative  arcus  irregularly  distributed  throughout 
cornea.  Mobility  of  eyeballs  not  impaired.  Pupils  small,  area  of  mo- 
bility small.  React  to  light  and  accommodation.  Pupils  remain  regular 
on  accommodation.    Considerable  contraction  of  visual  field  of  both  eyes. 

8ensation.-r-'Blxa\img  of  cutaneous  tactile  sensibility ;  a  sharp  jiencil 
feels  like  the  finger,  and  he  says  he  cannot  distinguish  the  contact  of  cot- 
ton from  contact  of  piece  of  soft  rubber.  Pain  conduction  not  delayed 
nor  diminished.  Discrimination  of  various  tactile  irritations  very  poor. 
No  hyperaesthesia.     Subjectively  has  para?stliesia  in  extremities  at  times. 

Hearing. — Can  just  hear  tick  of  watch  when  brought  in  contact  with 
left  ear,  but  not  in  right  ear.     Bone  conduction  appai-ently  diminished. 

Pulse. — Regular,  78  ;  moderate  capacity,  slight  increased  tension. 

Temperature. — Slightly  subnormal,  98°  F. 

Speech. — Markedly  scanning,  and  biting  of  syllables.  Tongue  not 
particularly  jerky.     Has  trouble  in  starting  speech. 

Mental. — Hopeful,  never  complains  ;  satisfied  and  complacent ;  mem- 
ory defective. 

Physical. — Extremities  rather  weak,  poor  grijj,  and  weak  resistance 
of  extensors  and  flexors. 

Diagnosis. — The  physician  who  is  called  upon  to  examine  cases  of 
this  kind  must  determine  whether  they  ai"e  cases  of  hysteria  major, 
paralysis  agitans,  disseminated  sclerosis,  or  are  simulators.  The  exist- 
ence of  hj^steria  major  must  be  tested  by  the  rides  which  will  be  laid  down 
later.  Paralysis  agitans  is  in  some  instances  caused  by  shock  or  injury ; 
its  characters,  however,  are  siifficiently  definite  to  enable  us  always  to 
distinguish  it.  The  tremor  is  segmental,  and  is  most  marked  during 
rest.  It  involves  one  side  of  the  body  more  than  the  other,  and  rarely 
the  face.  There  is  no  speech-disturbance  and  no  nystagmus.  There 
is  a  gradual  development  of  muscular  rigidity  with  the  tremor.  The 
patients  also  suffer  nnicli  from  sensory  disturbances,  such  as  pains  along 
the  course  of  the  nerves,  sensations  of  heat,  and  numbness  or  prickling. 
The  voice  of  the  patient  becomes  feeble,  high-pitched,  or  senile  in  char- 
a^cter.     There  is  a  peculiar  flush  of  the  face  due  to  vasomotor  paralysis. 


334  A   SYSTEM  OF  LEGAL  MEDICINE. 

The  detection  of  simulation  mnst  be  made  out  by  the  methods  described 
later.  It  would  be  very  difficult  for  a  patient  successfully  to  simulate 
the  coarse  intentional  tremor,  the  syllabic  speech,  and  contracted  visual 
fields  of  this  disorder. 

Prognosis. — The  prognosis  in  this  class  of  cases  is  bad.  The  patients 
reach  a  certain  stage  in  which  they  are  able  to  be  about,  but  are  of  little 
use  to  others  or  to  themselves.  They  do  not  suffer  much  pain,  and  some- 
times are  hopeful  and  cheerful.  Reaching  this  chronic  stage,  the  disease 
progresses  very  slightly,  and  they  may  live  for  many  years ;  but  recovery 
is  extremely  rare,  and  if  it  occurred  we  should  be  obliged  to  consider  that 
a  large  part  of  the  symptoms  were  hysterical. 

Pathology. — It  is  becoming  more  and  more  my  conviction  that  all 
cases  of  multiple  sclerosis  are  either  traumatic  neuroses  or  are  the  re- 
sult of  acute  infectious  diseases.  The  j)athology,  therefore,  of  the  grave 
traumatic  neurosis  would  be  nothing  different  from  that  which  is  usu- 
ally described  as  the  pathology  of  disseminated  sclerosis  due  to  other 
causes.  If  any  actual  organic  disease  exists  in  this  class  of  cases  it  must 
be  one  that  is  produced  by  small  multiple  hemorrhages  which  set  up  foci 
of  softening,  followed  by  a  reparative  process  that  leads  to  the  develop- 
ment of  small  connective-tissue  nodules  in  the  brain  and  to  a  less  extent 
in  the  spinal  cord.  It  is  not  my  purpose  to  go  further  into  the  descrip- 
tion of  a  process  of  which  full  accounts  are  given  in  systematic  text-books. 
It  may  be  said,  however,  that  the  anatomical  condition  underlying  a 
traumatic  multiple  sclerosis  is  more  favorable  than  that  underlying  one 
that  follows  infectious  fevers,  for  the  reason  that  in  the  latter  case  some 
microbic  poison  may  be  associated  with  the  development  of  each  diseased 
focus.  In  both  forms  of  trouble  there  seems  to  be  the  same  tendency  for 
the  nodules  of  sclerosis  to  be  situated  most  frequently  in  the  white  matter, 
especially  in  that  of  the  pons,  internal  ca]3sule,  and  centrum  ovale.  The 
cranial  nerve  roots  are  sometimes  affected  and  also  the  spinal  cord,  but 
the  diseased  process  is  essentially  a  cerebral  one. 


TRAUMATIC   HYSTERIA. 

Hysteria  is  a  chronic  functional  brain  disorder  characterized  by  nerv- 
ous attacks  or  crises,  and  by  a  peculiar  interparoxysmal  state  in  which 
.certain  marks  or  stigmata  are  present.  There  are  two  forms  of  hysteria, 
the  hysteria  minor  and  hysteria  major.  Hysteria  minor  is  that  form 
of  the  morbid  condition  which  is  generally  meant  by  the  term  hysteria. 
It  is  the  hysteria  of  popular  conception  and  of  general  medical  parlance. 
In  hysteria  minor  there  is  simply  an  exaggeration  of  the  emotional  side, 
together  with  outbreaks  of  various  kinds,  such  as  crying  or  laughing, 
fainting-attacks  or  convulsions.  This  minor  hysterical  condition  is  pres- 
ent in  men  and  the  great  majority  of  women,  and  it  is  not  always  to  be 
considered  a  disease.  It  is,  however,  when  associated  with  neurasthenia 
or  with  other  neuroses,  often  an  unpleasant  and  disagreeable  complica- 
tion. It  is  not  of  the  hysteria  minor  that  we  speak  when  we  use  the  term 
traumatic  hysteria.  Traumatic  hysteria  is  really  a  major  hysteria,  and  it 
is  a  definite  disorder,  quite  different  in  its  essential  characters  from  that- 
malady  which  is  popularly  understood  as  hysteria.  In  hysteria  major 
there  is  a  decided  and  serious  disturbance  of  certain  special  functions  of 


THE    TRAUMATIC  NEUROSES.  33.3 

the  brain.  As  a  result  of  tliis  we  have  severe  crises  or  attacks,  during 
which  the  patients  exhibit  convulsive  or  other  explosive  phenomena,  and 
we  have  between  these  paroxysms  very  striking  symptoms,  consisting  of 
anaesthesia,  paralyses,  contractures,  ti-emors,  peculiar  mental  conditions, 
and  even  vasomotor  and  troi)hic  disturljances.  Traumatic  hysteria  majcjr 
is  essentially  the  same  disease  as  hysteria  major  due  to  other  causes. 

In  making-  a  study  of  the  aiuesthesias  of  twelve  cases  of  major  hys- 
teria some  years  ago  I  found  that  four  of  them  were  of  traumatic  origin, 
and  the  clinical  history  of  these  four  cases  was  not  essentially  different 
from  that  of  the  other  eight.  In  a  description  of  traumatic  hysteria, 
therefore,  I  shall  have  to  go  over,  to  a  certain  extent,  the  same  gi'ound 
that  woidd  be  taken  in  the  systematic  description  of  this  disease.  Let 
me  say  now  that  in  using  the  term  hysteria  in  this  connection  I  shall 
mean,  unless  I  specify  otherwise,  hj'steria  major. 

Age. — The  traumatic  form  of  hysteria  occm-s  chiefl}^  in  middle  life. 
Berbez  found  the  average  age  of  21  cases  to  be  25  years,  the  range  being 
19  and  56.  Thorburn  found  the  average  age  to  be  31  among  17  cases, 
being  28.}  in  the  female  and  35  in  the  male  ;  the  range  was  from  18  to  42. 
Among  16  of  my  own  cases  the  average  age  was  33,  the  range  being  from 
14  to  54.     The  age  of  the  female  cases  is  younger  than  that  of  the  male. 

Sex. — The  disease  occurs  oftener  in  men  than  in  women.  This  is  the 
experience  of  Berbez,  who  found  14  males  to  7  females,  and  in  my  own 
cases,  where  there  were  11  males  to  5  females  among  16  cases.  Thorburn 
would  explain  this  on  the  ground  that  more  men  are  injured  than  women 
in  railwaj^  accidents.  Few  of  my  cases,  however,  were  railway  cases,  but 
were  injured  by  electric  shocks,  by  falls,  or  blows.  Thorbui-n  states, 
however,  that  among  228  persons  injured  in  railway  accidents  there  were 
157  males  and  71  females.  Among  the  former  there  were  10,  among  the 
latter  13  cases  of  hysteria,  so  that  he  estimates  that  the  probabilities  of 
a  railway  accident  being  followed  by  hysteria  are  three  limes  as  great  in 
the  female  as  in  the  male.  Thorbm-n  probably  uses  the  term  hysteria  in 
a  less  definite  sense  than  I  do.  In  my  experience  hysteria  major  is 
rarely  found  in  women  who  have  suffered  from  railway  accidents.  They 
more  frequently  develop  spinal  irritations,  functional  spinal  palsies,  and 
hysteria  minor  or  neurasthenia.  Marriage  has  no  effect  upon  males, 
but  unmarried  women  ai'c  perhaps  somewhat  more  susceptible  than  the 
married. 

Race. — Hysteria  of  the  major  type  is  apparentl}"  much  more  common 
in  France  than  in  other  countries.  English  observers  state  that  it  is 
rarely  seen  in  that  country-.  In  Germany  it  seems  to  be  a  relatively  fre- 
quent traumatic  neurosis.  In  this  country  traumatic  hysteria  is  less 
frequent  than  traumatic  neurasthenia.  In  Walton's  experience  the  per- 
centage of  hysterical  cases  was  17  ;  in  Knapp's,  15.  In  my  own  experience 
I  have  had  an  apparently  unusual  percentage  of  hysteria,  for  I  found 
that  among  33  carefully  recorded  cases  of  traimiatic  neuroses  16  were 
cases  of  lij' steria.  About  one  third  of  these  were  of  German  or  of  Russian 
origin,  one  fom-th  of  Irish,  and  the  rest  were  of  American  parentage. 
Chronic  alcoholism  predisposes  to  a  development  of  traumatic  hysteria. 
Every  year  I  find  in  the  alcoliolic  cells  at  Bellevue  one  or  two  cases  of 
typical  hysteria  occurring  in  chronic  alcoholics  who  have  been  subjected 
perhaps  to  some  blow  or  shock.  Traumatic  hysteria,  however,  occurs  in 
persons  of  perfectly  temperate  habits,  and  in  most  of  my  traumatic  cases 


336  A   SYSTEM  OF  LEGAL  MEDICINE. 

no  history  of  alcoholism  was  noted.  Traumatic  hysteria  occurs  more 
frequently  among  men  of  the  lower  social  class — that  is  to  say,  among 
laboriug'-men  and  mechanics  and  men  who  are  subjected  to  hard  work 
and  privation. 

The  influence  of  heredity  has  been  much  dwelt  upon  by  French  writers. 
Charcot  maintains  that  there  is  always  or  nearly  always  some  hereditary 
taint.  The  German  writers  do  not  take  this  view,  and  in  my  own  cases 
there  is  no  evidence  that  heredity  plays  any  important  part ;  certainly  in 
none  of  my  eases  was  there  discoverable  any  serious  neurosis  or  psychosis 
in  the  family.  The  patients,  however,  were  many  of  them  of  a  neurotic 
temperament,  but  perhaps  no  more  so  than  many  other  persons  who 
have  not  been  victims  of  major  hysteria. 

The  exciting  cause  is  the  injury.  In  my  experience  an  electrical  shock 
has  a  particularly  powerful  effect  in  producing  traumatic  hysteria.  Three 
of  my  sixteen  cases  developed  hysteria  in  this  way.  In  one  ease,  however, 
the  patient  did  not  actually  get  a  shock,  but  only  thought  that  he  got 
one.  The  nature  of  the  injury  does  not  seem  to  be  of  nearly  as  much  im- 
portance as  the  fact  that  the  surrounding  circumstances  excite  intense 
fear.  However,  it  seems  likely  that  blows  upon  the  head  are  rather  more 
apt  to  produce  hysteria  than  contusions  or  injuries  of  other  parts.  I  do 
not  know  of  any  case  in  which  a  person  got  hysteria  if  he  was  injm-ed 
while  intoxicated  or  asleep.  Direct  injmy  to  a  nerve  is  said  by  Thorburn 
to  be  a  potent  cause  of  producing  hysteria.  The  climate  and  season  of 
the  year  seem  to  have  no  special  effect  upon  the  disorder,  other  than  that 
hysteria  is  more  prevalent  in  temperate  chmates  and  in  large  and  popu- 
lous cities.  The  person's  state  of  mind  previous  to  the  injury  prepares 
the  way  for  the  development  of  the  neurosis.  Thus  if  a  person  travels 
with  a  mind  full  of  alarm  and  agitation  over  some  possible  calamity,  the 
hysteria  would  be  more  likely  to  develop  should  such  an  accident  actually 
occur.  This  is  weU  illustrated  in  the  case  of  a  patient  of  mine  who  had 
read  of  the  killing  of  a  man  by  an  electric  wire.  A  few  days  after  he  was 
walking  along  the  street,  when  suddenly  a  dead  wire  fell  and  struck  him 
on  the  head.  The  blow  was  not  very  severe,  nor  was  there  any  electrical 
current  passing  through  the  wire,  but  the  man  fell  unconscious,  and  when 
he  was  aroused  he  was  found  to  have  a  typical  hysterical  hemiplegia  with 
hemiansesthesia.  The  fact  may  well  be  borne  in  mind  that  traumatic 
hysteria  may  be  produced  by  surgical  operations,  and  especially,  in  my 
experience,  by  minor  operations  conducted  under  cocaine  rather  than 
under  ether.  Operations  upon  the  nose  and  throat  and  minor  operations 
upon  the  uterus  are  not  infrequently  followed  by  nervous  and  hysterical 
disorders. 

Symptoms. — The  disease  develops  in  different  ways ;  it  may  be  either 
gradual  or  sudden.  In  some  cases  the  ]3atient  receives  an  injury  or 
fright,  and  at  once  becomes  excessively  excited,  and  perhaps  even  deliri- 
ous for  a  few  hours.  Upon  becoming  quiet  it  is  noticed  that  one  half  of 
the  body  is  paralyzed,  and  upon  further  examination  it  is  found  that  there 
is  a  loss  of  sensibility  upon  this  same  side,  and  that  all  the  classical  sjrmp- 
toms  of  a  hj^sterical  hemiplegia  have  developed.  In  other  cases  the 
patient  after  a  fright  or  shock  falls  down  in  a  state  of  unconsciousness 
or  passes  into  an  hysterical  attack,  during  which  violent  convulsive  move- 
ments are  made.  After  emerging  from  this  attack  he  is  found  to  be 
suffering  from  some  form  of  hysterical  paralysis.     In  still  other  cases  a 


PLATE  IV. 


■i^^'''^'»,C"      *  "-^  "'^ 


HYSTERICAL  HEMIPLEGIA,  showing  the  peculiar  dragging  of  the  foot. 


THE  TRAUMATIC  NEUROSES.  339 

person  receives  an  injury,  becomes  somewhat  stunned  or  prostrated,  but 
recovers  and  goes  home  or  resumes  liis  Avork.  In  the  course  of  a  few 
days  he  notices  that  he  suffers  from  headaches  and  sleeplessness ;  that  he 
is  irritable  and  easily  excited,  and  is  entirely  unlike  himself.  After  a  few 
weeks  he  perhaps  gives  up  his  work,  and  during  this  time  he  has  attacks 
of  swooning  or  of  cataleptic  or  convulsive  character.  These  attacks  are 
alarming,  but  they  pass  away  and  he  continues  to  be  simply  suffering 
from  a  nervous  irrital)ility  and  depression,  with  more  or  less  vague  pains 
about  the  head  and  Ijack.  The  picture,  in  other  words,  is  much  like  that 
of  a  traumatic  neurosis.  In  the  course,  however,  of  a  few  weeks,  or  per- 
haps even  months,  there  develop  symptoms  of  a  much  more  severe  char- 
acter. The  patient  is  found  to  lose  the  power  of  one  side  of  the  body,  or 
perhaps  to  be  gradually  becoming  paraplegic ;  and  associated  with  this 
condition  of  paralysis  are  found  disorders  of  sensation  and  other  sjonp- 
tonis  of  the  hysterical  condition.  In  a  tAT3ical  case  of  traumatic  hys- 
teria the  symptoms  may  be  described  very  much  as  follows :  The  patient 
is  usually  a  man  of  middle  age.  He  suffers  from  a  paralysis  of  the  arm 
and  leg  on  the  same  side — in  other  words,  a  hemiplegia.  This  paral- 
ysis affects  most  the  arm  and  less  the  leg,  while  the  face  itself  is  not  in- 
volved. The  paralysis  is  never  absolute.  The  patient  can  move  the  arm 
a  little  and  can  draw  up  the  leg  and  often  can  walk  about,  though  Tvdth 
some  difficulty.  The  hemiplegia  is  of  a  flaccid  type — that  is  to  say,  there 
is  none  of  the  rigidity  associated  with  hemiplegia  due  to  organic  lesion. 
The  reflexes  at  the  knee  are,  if  anything,  diminished,  though  sometimes 
slightly  exaggerated,  but  there  is  no  ankle-clonus.  The  gait  of  the  pa- 
tient with  this  hysterical  hemiplegia  is  characteristic  :  instead  of  swinging 
the  foot  round  in  a  semicircle  as  in  organic  hemiplegia,  the  paralyzed  foot 
is  dragged  in  a  nearly  straight  line,  the  toe  scraping  the  floor.  (See  PI.  II.) 
The  absence  of  paralysis  of  the  face  is  characteristic.  Sometimes  there 
is  said  to  be  an  apparent  facial  paralysis,  which  is,  however,  really  due  to 
facial  spasm.  The  tongue  when  protruded  goes  out  straight,  as  a  rule, 
but  sometimes  it  turns  over  toward  the  paralyzed  side,  owing  to  spasms 
of  the  muscles  of  that  side.  This  lingual  spasm  is  an  interesting  char- 
acteristic of  traumatic  hysteria.  The  patient  has  sometimes — in  fact,  in 
the  majority  of  cases — along  with  this  hemiplegia  a  tremor  of  the  arms 
and  to  a  less  extent  of  the  lower  limbs  and  facial  muscles.  This  tremor 
is  more  marked  on  the  paralyzed  side.  It  has  the  characteristics  gener- 
ally of  the  tremor  of  a  multiple  sclerosis,  though  it  is  often  even  more 
exaggerated  and  jerk3\  The  tremor  ceases  when  the  hand  is  quiet ;  it 
begins  when  voluntary  motion  is  made,  and  it  becomes  A-ery  exaggerated 
in  attempts  to  place  the  finger  upon  some  definite  part  of  the  body  or  to 
use  some  instrument  in  a  definite  muscular  action.  This  tremor  ceases 
during  sleep.  It  affects  sometimes  the  tongue,  producing^  a  peculiar 
nervous  articulation,  not  exactly  like  that  of  multiple  sclerosis,  but  more 
like  that  of  an  excessively  excit^ed  man.  There  is  no  nystagmus,  nor  is 
there  usually  much  tremor  of  the  face,  though  this  may  be  slightly  pres- 
ent. The  tremor  as  I  have  described  it  is  often  not  very  much  marked, 
and  it  may  be  even  practically  absent.  There  is  no  atrophy  of  the  mus- 
-cles  of  the  affected  side,  nor  are  there  any  electrical  degeneratiA'e  reac- 
tions. Vigouroux  at  one  time  stated  that  there  was  an  increase  in  the 
resistance  of  the  paralyzed  limb  to  the  electrical  current  over  the  limb 
on  the  sound  side,  and  this  is  occasionally  observed.     The  patient  is 


340 


A   SYSTEM  OF  LEGAL  MEDICINE. 


found  to  suffer  not  only  witli  a  paralysis  on  one  side  of  the  body,  but 
with  an  ana?sthesia  of  the  skin  upon  this  side.  This  cutaneous  anaBS- 
thesia  in  some  instances  involves  the  whole  of  the  paralyzed  side  of  the 
body  from  head  to  foot,  stopping  sharply,  however,  and  absoluteh",  at 
the  middle  line.  Such  extensive  aneesthesia  is  rare.  More  often  the 
anaesthesia  involves  the  foot  and  leg  up  as  far  as  the  middle  of  the  thigh, 
the  arm  up  to  near  the  shoulder,  and  the  side  of  the  head  ;  in  other  words,  it 
has  what  Charcot  has  called  the  gauntlet  and  stocking  type.    (See  Fig.  53.) 


Fig.  53,  showing  the  different  modes  of  hysterical  ansesthesia.    The  dark  spots  indicate 

hysterogenic  zones. 


The  an£esthesia  may  extend,  however,  to  the  other  side,  so  that  there  is  a 
bilateral  anaesthesia.  This  is  extremely  rare,  especially  in  traumatic  cases. 
The  anaesthesia  may  occui'  in  zones  or  patches  on  the  surface  of  the  limbs 
or  the  head.  These  zones  or  patches  do  not  correspond  mth  the  distri- 
bution of  any  nerves,  and  in  this  respect  they  are  characteristic  of  a 
hysterical  condition.  The  anesthesia  much  more  frequently  affects  the 
arm,  leg,  and  face  together ;  next  in  frequency  the  arm  and  leg ;  then 
come  the  ii-regular  tyj)es  that  I  have  spoken  of.  In  some  instances  the 
anesthesia  may  be  crossed — that  is  to  say,  there  is  anesthesia  on  one 
side  of  the  face  and  on  the  opposite  side  of  the  body.  The  anesthesia 
as  well  as  the  paralysis  is  usually  found  to  be  on  the  same  side  as  the 
injurj^,  particularly  if  the  injury  is  a  blow  on  the  head.  This  fact  is 
often  an  important  and  practical  one.  A  blow  upon  the  right  side  of 
the  head,  for  example,  if  it  produces  a  hemiplegia  from  organic  disease, 
would  produce  a  hemiplegia  on  the  left  side  of  the  body ;  but  if  it  pro- 
duces hemiplegia  of  a  functional  or  hysterical  character  tins  will  occur  on 
the  same  side  as  the  external  lesion. 

Regarding  the  character  of  the  cutaneous  anesthesia  I  have  made  a 
number  of  observations.*  I  have  found  that  the  touch  sense  was  the  least 
affected,  while  the  reaction  to  painful  sensations  was  most  frequently  and 


1890. 


"A  Study  of  the  Anaesthesias  of  Hysteria,"  Amer,  Jour.  Med.  Sciences,  October, 


THE   TRAUMA  TIC  NEUROSES. 


;54i 


inost  extensively  abolished.  Between  these  two  eanie  the  teinperatnre 
iuuesthesia.  I  fouiul  also  that  there  was  very  rarely  any  ana'sthesia  of 
the  nius(nilar  sense  or  artienlar  sense  exeept  when  the  paralysis  was  very 
profonnd.  This  lattt'r  eonelusion  is  at  varianee  with  the  theories  of  Dr. 
Bastian  and  with  some  of  the  data  wliieh  he  has  eolleeted.  However,  I 
"believe  it  will  be  found  that  in  moderate  grades  of  hysterical  hemiplegia 
there  is  no  great  degree  of  ataxia  or  disturbance  of  muscle  or  articular 
siMisation  ;  (certainly  this  is  the  experieuce  in  a  numl)er  of  very  carefully 
ol)served  eases  of  my  own.  When,  however,  the  paralysis  is  absolnte, 
there  is  undoul)tedly^  in  most  cases,  if  nc^t  all,  nuiscular  auajsthesia  also. 
(fSee  Figs.  54,  55,  5G,  and  57.) 


Fig.  54.  Fig.  .5.5.  Fig.  56. 

Figs.  .54  to  57  show  bv  contrast  the  distribution  of  anaesthesia  in  lesions  of  the  cauda 
equina  (Figs.  .54,  .55,  50)  and  in  myelitis  Fig.  57,  on  next  page),  as  compared  with  that  in  hys- 
teria (Fig.  53). 

Besides  the  cutaneous  anaesthesia  there  is  an  anaesthesia  of  the  special 
senses — of  sight,  hearing,  taste,  and  smell — upou  the  affected  side.  There 
may  be  a  very  great  dimming  of  the  vision  of  the  eye  of  the  affected 
side,  but  as  a  rule  the  disturbance  consists  in  a  concentric  limitaticm  of 
the  visual  field.  With  this  phenomenon  there  is  at  times  a  change  in 
the  color  sense  and  in  the  color  fields.  In  some  cases  the  only  trouble 
consists  in  a  disorder  of  the  color  fields,  and  in  some  cases  there  is  an 
actual  loss  of  color  sense  altogether.  I  have  observed  this  in  two  cases. 
Drs.  Mitchell  and  De  Schweinitz,  who  have  made  a  study  of  this  subject, 
failed  to  find  it  in  a  series  of  twenty-five  cases,  not,  however,  of  traumatic 
■character.*    The  green  field  is  relatively  more  and  more  often  contracted 

*  Complete  studies  of  tliis  subject  liave  been  made  by  Pausiea  {Ocular  Manifesta- 
tions of  Hjistcria,  Paris,  1802),  by  Wildbvand  and  Sanger,  by  FraMikel,  Hopevart,  and 
■To))()laHski,  by  Willielm  Koiiig,  and  very  recently  l)y  Mitchell  and  Pe  Schweinitz 
(.lonrnal  of  Kcrroits  and  Mental  Disrase,  January,  1894),  wlio  give  a  full  bibliography. 
These  latter  authors  give  specific  directions  for  testing  the  concentric  limitation  of 
the  visual  field.  Tlieir  tests  were  nnide  by  means  of  the  perinuner.  The  test-objects 
were  white  and  colored  cards  1 1  cm.  in  diameter.  The  patient  is  placed  in  a  good 
liglit,  and  the  test  must  be  made  in  several  different  ways.  First,  for  near  objects :  in 
this  case  the  test-card  is  moved  from  without  inward,  and  the  point  noted  where  it  is 


342 


A   SYSTEM  OF  LEGAL  MEDICINE. 


than  tlie  others.  (See  Figs.  58  and  59.)  Reversal  in  the  normal  sequence- 
of  the  colors,  so  that  red  is  the  largest  field,  is  usually  present,  the  normal 
order  being  bine,  red,  and  green.  The  field  of  vision  is  contracted  in  both 
eyes,  but  more  on  the  affected  side.  The  contraction  is  always  more  or 
less  concentric,  and  does  not  present  the  characters  of  a  hemianopsia — 

that  is  to  say,  the  visual  field  is  con- 
tracted at  all  points  of  its  circumfer- 
ence, and  there  is  no  half -blindness, 
either  horizontal  or  vertical.  To  this 
rule  Mitchell  and  De  Schweinitz 
have  reported  an  apparent  exception 
{loc.  cit.). 

The  hearing  on  the  affected  side 
is  sometimes  much  impaired,  and  is 
almost  uniformly  affected  in  some 
way  or  other.  The  most  frequent 
disturbance  is  a  diminution  of  hear- 
ing or  absolute  deafness  to  bone 
conduction,  while  hearing  is  fairly 
good  to  aerial  conduction.  Loss  of 
the  power  of  hearing  high  notes  and 
very  low  notes  is  also  a  frequently 
observed  phenomenon.  The  deaf- 
ness to  high  notes  occurs  almost 
without  exception,  as  tested  by  a 
Galton  whistle.  Deafness  to  low 
notes  I  have  found  in  only  two  or 
three  cases.  In  these  the  patients 
were  unable  to  hear  a  note  made 
by  the  bass  strmg  of  a  viol  giving 
vibrations  of  about  34  or  68  per  sec- 
ond. The  senses  of  smell  and  of  taste 
are  abolished  on  the  affected  side. 

The  most  striking  symptoms  of 
hysteria  major  are  those  that  I  have 
just  described — paralysis  and  anaes- 
thesia. The  distribution  of  these 
symptoms,  however,  is  not  always 
hemiplegic.  Sometimes  a  patient 
suffers  from  simply  a  paral}' sis  of  one  arm  or  of  a  leg,  or  of  both  legs.  An 
hysterical  paralvsis  of  an  arm  is  the  more  common.  Hj'sterical  paraplegia 
is  relatively  rare,  particularly  the  cases  which  can  lie  spoken  of  as  in  a 
true  sense  hysterical,  that  is,  of  cerebral  origin.  When  the  patient  suf- 
fers from  an  In^sterical  arm-palsy  he  has,  along  with  the  palsy,  which  is 
flaccid  in  tNqDe,  anaesthesias  of  the  skin  and  perhaps  of  the  muscles,  and 
he  has  at  the  same  time  some  of  the  an9ethesia,s  of  the  visual,  auditory, 


Fig.  57. 

Distribution  of  anaesthesia  in  a  case  of 

myelitis. 


first  recognized.  Then  it  is  to  be  moved  from  within  outward  and  the  point  again 
noted.  It  is  well  to  repeat  this  procedure  once  or  twice.  If  there  is  ground  for 
suspecting  simulation  the  test  must  then  be  repeated  with  the  test-object  held  some 
five  or  six  feet  away,  and  the  results  compared  with  those  obtained  at  a  nearer  dis- 
tance. The  accompanying  chart  represents  the  physiological  limits  of  the  field  for 
form  and  for  blue,  red,  and  green.     (Fig.  58,  p.  343,  also  Fig.  59.) 


THE   TRAUMATIC  NEUROSES, 


343 


and  other  special  senses.  If  a  person  suffers  from  hysterical  paraplegia 
of  a  t3q)e  that  is  truly  liysterical,  lie  will,  I  am  convinced,  have  along 
with  this  paraplegia  some  disturlj- 
ance  of  cutaneous  sensation  of  the 
affected  parts.  There  will  be  also 
some  evidences  of  disturbance  of  the 
special  senses,  and  often  there  occur 
certain  disorders  of  motor  cranial 
nerves,  more  especially  a  hngual 
spasm.  In  hysterical  para})legia 
there  is  some  exaggeration,  as  a  I'ule, 
of  knee-jerks,  and  after  a  long  period 
of  time  thei'e  may  be  contractures. 
There  are,  however,  in  the  early 
stages  no  muscular  atrophies  and  no 
changes  to  the  electrical  currents. 
There  may  be  a  slight  disturbance  of 
the  bhidder  for  a  time,  but  no  persist- 
ent impairment  of  its  f  unction .  I  am 
convinced,  with  Dr.  Bastian,that  as  we 
become  more  familiar  with  the  char- 
acters of  these  paraplegias  we  shall 
be  less  inclined  to  consider  them  all  as  of  cerebral  or  hysterical  origin,  but 
rather  to  place  some  among  the  functional  paralyses  of  spinal  character. 


Fig.  58.    Diagram  of  the  normal  field  of 

vision  of  the  riglit  eye  for  hlue,  red,  and 
green.  The  outer  continuous  line  indicates 
the  limit  of  the  form  field ;  the  broken  lines, 
the  limits  of  the  color  fields.  (De  Schwei- 
nitz  and  Mitchell.) 


Fig.  59. 


Diagram  of  the  normal  field  of  vision  of  left  eye  for  form  blue,  red,  and  green. 
(Landolt.) 


Besides  the  symptoms  of  heitiiplegia  and  sensory  disorders  there  are  other 
troubles  from  which  these  patients  suffer.     As  a  ride,  the  patient  is  very 


344  ^   SYSTEM  OF  LEGAL  MEEICIXE. 

mucli  depressed  mentally  and  discouraged  about  himself.  (See  PL  T ) 
He  suffers  a  great  deal  from  pains  in  the  back  and  limbs  and  hip,  and  is 
apt  to  be  of  a  very  complaining  habit.  He  is  usually  emotional,  and  ciies 
easily.  He  is  persistent  in  his  expressions  of  a  desire  to  get  well,  and 
will  usually  carry  out  very  faithfully  the  directions  given  to  him  by  his 
physician.  He  has  at  times  hysterical  attacks  or  crises.  In  men  these 
attacks  seem  to  take  more  often  the  character  of  simple  comatose  or  le- 
thargic stages,  the  patient  passing  off  for  a  few  minutes  or  hours,  or  even 
days,  into  a  state  of  what  resembles  hypnotic  sleep  or  lethargy ;  at  other 
times  the  patients  have  emotional  and  almost  maniacal  attacks  or  decided 
convulsive  seizures,  and  more  rarely  go  thi-ough  the  characteristic  hys- 
tero-epileptic  phenomena.  I  have  never,  however,  in  this  country,  seen 
the  typical  hystero-epileptic  attacks  develop  in  males  with  hysteria  of 
traumatic  origin.  Again,  the  patients  may  suffer  from  violent  and  obsti- 
nate attacks  of  vomiting.  Nearly  all  the  cm-ious  and  weird  manifes- 
tations of  hysteria  may  be  exhibited  by  these  patients — the  cutaneous 
eruptions,  the  edematous  swellings,  the  anuria,  the  visceral  crises,  the 
palpitations,  the  anginal  attacks,  and  so  on.  Sometimes  there  may  be 
attacks  of  hysterical  mutism.  It  is  not  necessary  for  me  to  go  into  de- 
tails of  this  character,  because  the  symptoms  are  those  which  will  be 
found  described  under  the  head  of  major  hysteria  in  special  treatises. 

I  have  found  in  my  experience  that  in  young  women  the  interpar- 
oxysmal  marks  of  hysteria,  such  as  the  auEesthesias  and  paralyses,  are 
less  common,  while  contractures  and  tremors  of  various  kinds  and  pain- 
ful neuralgic  disorders  are  more  frequently  observed.  In  traumatic  hys- 
teria in  women  also  crises  of  various  kinds,  more  particularly  convulsive 
attacks,  are  much  more  frequent.  I  believe  that  I  cannot  better  supple- 
ment a  description  of  traumatic  hysteria  than  by  giving  the  history  of 
certain  typical  cases  of  this  disorder.  The  first  is  that  of  a  man  who 
illustrated  in  a  classical  way  the  ordinary  symptoms  of  traumatic  hysteri- 
cal hemiplegia.  The  second  case  illustrates  a  somewhat  irregular  type  of 
this  disorder,  occurring  also  in  a  man.  The  third  case  illustrates  the  de- 
velopment of  traumatic  hysteria  in  a  young  woman. 


Case  I. 

Traumatic  Hysteria. — B.  N.,  aged  fifty ;  married ;  Moravian  by  birth ; 
clerk.  Mr.  N.  states  that  he  has  always  been  well,  is  of  temperate 
habits,  has  had  no  venereal  disease,  has  a  family  of  five  childi'cn,  all 
healthy.  He  was  walking  along  the  street  September,  1889,  at  the  time 
of  the  great  excitement  about  street  currents,  when  he  saw  a  mre  from 
an  electric-light  pole  falling  toward  him.  The  wii'e  struck  him  across 
the  head,  making  a  welt  on  his  derby  hat ;  he  seized  it  in  his  right  hand. 
He  does  not  remember  any  more  until  he  came  to  in  New  York  Hospital. 
He  is  said  to  have  faUen  down,  then  to  have  been  helped  up,  and  to  have 
walked  with  some  assistance.  When  struck,  he  saw  a  bright  light,  but 
felt  no  peculiar  sensations  of  any  kind. 

When  admitted  to  the  hospital  he  was  conscious  and  soon  able  to 
talk,  losing  his  amnesia  except,  as  he  says,  of  the  events  just  after  the 
blow.  There  was  a  black  stain  on  his  right  hand,  but  no  burn.  His 
right  arm  and  hand  and  leg  were  paralyzed,  the  leg  almost  completely, 


H 
< 

Q. 


THE    TI!  ALMA  TIC  X  EL  ROSES.  347 

SO  that  he  eoiihl  not  walk.  Tlie  face  or  tono-ne  was  not  involved.  There 
was  complete  hemianu'stliesia.  of  the  right  side  of  tlie  Ixxly.  The  l)ladder 
was  normal.  The  mental  condition  t^'ood,  tliou;^h  lie  did  not  sleep  well  for 
a  few  uig'hts.     The  abdominal  and  tiioi-acic  viscera  seemed  to  be  normal. 

Throng'h  the  kindness  of  tlu^  visit inij;'-])hysiciiin,  Dr.  William  (1.  Thomp- 
son, and  the  house  physician,  Dr.  C-obb,  I  was  enabled  to  make  an  exam- 
ination of  the  patient,  September  24th.  He  was  then  able  to  walk  slowly 
iind  to  use  his  right  arm  faiiiy  well.  He  seemed  to  be  an  intelligent 
man,  somewhat  emotional,  but  anxious  to  tell  the  truth  about  his  symp- 
toms and  to  get  well  and  back  to  his  work.  His  mind  was  clear,  and  he 
suffered  from  no  emotional  depression  or  ciises.  He  was  sleeping  well. 
His  pulse  was  quite  rapid  (120)  under  iwy  examination,  l)ut  it  had  been 
normal,  as  were  the  temperature  and  respiration. 

The  face  showed  no  paralysis,  the  tongue  was  protruded  straight,  and 
the  pharyngeal  arch  was  even.  The  right  arm  was  weak,  but  he  could 
execute  all  movements  with  it  except  raising-  it  directly  over  his  head. 
Dynamometer :  right  hand,  25  ;  left  hand,  40.  There  was  a  tremor  in 
the  arm  and  hand  and  occasionally  in  the  leg;.  This  tremor  was  rapid, 
but  of  rather  large  excursion,  and  increased  on  voluntary  movement,  or 
on  directing-  attention  to  it.  It  was  an  "intention"  and  "attention" 
tremor.  It  did  not  affect  the  face  or  tongue.  Si3eech  was  clear  and  deg- 
lutition normal.  The  leg  was  much  more  paretic  than  the  arm.  The 
foot  and  toes  could  barely  be  moved,  the  leg*  could  be  flexed  and  extended 
but  partially.  The  tendon  reflexes  of  arm  and  leg  were  present,  but  not 
exaggerated.  The  skin  reflexes  were  well  marked.  There  was  anees- 
thesia  in  varying  degree  over  the  right  side  of  the  body.  It  was  most 
marked  in  the  lower  limb,  where  it  extended  diffusely  up  to  about  Pou- 
part's  ligament  in  front  and  the  gluteal  fold  behind.  In  the  arm  the 
anaesthesia  was  more  marked  over  the  area  of  the  ulnar,  but  it  was  pres- 
ent in  a  degree  over  tlie  whole  extremity.  Around  the  shoulder  and  neck 
it  became  less.  It  was  present  over  the  right  half  of  the  face,  including 
the  tongue,  but  Avas  less  marked  here  than  on  the  extremities.  The  anass- 
tliesia  was  most  marked  for  cold  sensations,  well  marked  for  pain,  and 
less  marked  for  tactile  sense.  There  was  no  muscular  aufpsthesia  or  loss 
of  coordination  as  tested  by  weights  and  by  touching  the  nose  and  postur- 
ing the  limbs. 

The  special  senses  showed  peculiar  conditions.  The  pupils  were  nor- 
mal, even,  and  reacted  to  light  and  accommodation.  There  was  no  color- 
blindness. The  man  was  presbyopic,  but  since  his  admission  he  had 
been  unable  to  read  well.  (He  had  broken  his  glasses.)  His  i-iglit  eye 
showed  decided  limitation  of  visual  field,  the  left  very  much  less,  though 
some  was  present.  No  difference  in  \dsual  acuteness  Avas  noted,  and  no 
hemianopsia. 

The  right  ear  showed  hearing  equally  acute  to  the  tick  of  a  watch 
or  the  voice  or  tuning-fork,  but  absolutely  deaf  to  l)one  conduction.  A 
large  tuning-fork  vibrating  on  the  mastoid  was  not  heard  ;  and  vibrating 
on  the  teeth  was  heard  only  by  left  ear.  Tested  by  Galton's  Avhistle, 
the  left  ear  showed  a  decided  loss  of  hearing  of  high  notes ;  the  right 
still  more.  I  had  never  met  befcn-e  a  person  so  deaf  to  so  great  a  range 
of  the  upper  notes,  though  it  is  not  very  uncommon  to  find  slight  degrees 
of  this  deafness  in  the  aged.  The  man  had  cvidimtly  a  limitation  of  the 
.auditory  field  eompanible  to  that  of  the  visual  field. 


348  ^   SYSTEM  OF  LEGAL  MEDICINE. 

There  was  an  almost  complete  loss  of  smell  in  the  right  nostril,  and  a^ 
complete  loss  of  taste  on  the  right  side  of  the  tongue.  There  was  also 
absence  of  pharyngeal  reflex  when  the  finger  was  thrust  into  the  back 
of  the  throat. 

There  were  no  manifest  secretory  or  trophic  disturbances  of  the  af- 
fected side.  The  man  complained  of  very  little  pain.  The  electrical  re- 
actions were  not  taken. 

We  have  here  a  case  of  traumatic  hysteria  of  the  tj^e  described  \>j 
Charcot,  G-uinon,  and  the  French  wiiters.  The  points  are  so  marked 
and  characteristic  that  a  discussion  as  to  diagnosis  would  be  supereroga- 
tory. We  have  the  (1)  hemiplegia  not  involving  the  face ;  (2)  the  anaes- 
thesia distributed  in  the  "  gauntlet"  sha];)e,  i.e.,  not  follo^\dng  nerve  tracts 
but  involving  mainly  the  limbs,  and  covering  them  like  a  stocking  or 
glove ;  (3)  we  have  the  peculiar  limitation  of  visual  field  (4)  and  auditory 
field,  the  bone-deafness,  (5)  the  ageusia  and  anosmia,  and  (6)  pharyngeal 
aneesthesia. 

Three  years  after  this  accident,  the  patient  was  much  improved  but 
far  from  well.     Case  in  litigation  and  not  settled. 

The  auditory  phenomena  are  particularly  interesting,  as  they  have 
not  been  investigated  mth  as  much  care  as  the  visual,  and  are  in  my 
experience  rarer.  The  loss  of  smell  on  the  right  side  is  confii-matory  of 
the  view  of  a  functional  hemiplegia ;  for  in  organic  hemiplegia  from  hem- 
orrhages, etc.,  it  is  sometimes  on  the  opposite  side  to  the  paralysis.  It 
has  also  been  claimed  that  the  olefactor}^  nerves  do  not  decussate,  and 
hence  that  hysterical  hemiageusia  is  only  apparent  and  due  to  trigeminal 
anesthesia.  This  would  not  explain  the  present  case.  For  the  trigemi- 
nal anaesthesia  was  very  slight  and  the  ageusia  almost  complete. 


Case  II. 

Trcmmatic  Hysteria  with  Violent  Tremor. — Mr.  X.,  aged  fifty-four ;  of 
American  bu*th  and  parentage ;  married ;  business  man.  The  family  his- 
tory is  good  in  every  way  so  far  as  any  details  can  be  obtained.  The 
patient  himself  had  always  been  an  active  business  man,  travehng  a  good 
deal.  There  is  no  history  of  syphilis  or  alcoholic  excesses ;  he  has,  how- 
ever, been  somewhat  excessive  in  sexual  indulgence.  He  had  never  suf- 
ered  from  any  serious  disease  or  injiu-y,  and  was  perfectly  well  at  the 
time  of  his  accident.  He  was  riding  on  a  horse-car  when  this  occurred. 
There  was  a  collision ;  his  car  was  suddenly  stopped,  and  he  was  thrown 
violently  against  another  person,  being  struck  on  the  side  of  the  head. 
He  was  not  knocked  down,  but  was  very  much  confused.  He  went  home^ 
however,  being  at  the  time  somewhat  excited  and  nervous  over  the  acci- 
dent, and  in  a  few  hours  passed  into  a  partially  comatose  state,  which 
lasted  for  two  days.  This  ended  in  a  violent  hysterical  outbreak  of  a 
maniacal  or  delirious  character.  This  had  subsided  in  the  course  of  a 
week,  and  he  was  then  found  to  be  unable  to  use  the  left  arm  or  leg. 
One  month  later  muscular  twitching  and  tremor  began  in  the  left  arm. 
This  tremor  extended  and  soon  involved  the  right  arm  and  the  muscles 
of  the  neck  and  head.  About  this  time  there  was  found  to  be  also  a  left 
hemianaesthesia.  He  complained  all  the  time  of  pains  in  the  neck  and 
head  while  these  various  phenomena  were  developed.     The  pains  in  the 


THE  TRAUMATIC  NEUROSES.  349 

head  and  neck  and  the  tremor  were  found  to  be  somewhat  relieved  by 
pulling  on  the  head,  so  that  his  physician  constructed  for  him  a  jury- 
must  by  which  pernument  supjxjj-t  was  given,  and  while  wearing  this  he 
stated  that  he  felt  more  comfortable.  He  was  able  to  walk  about,  though 
not  without  much  difficulty.  The  patient  was  brought  to  me  by  his  i>hy- 
sician.  Dr.  Gray,  for  examination  while  in  this  condition,  some  six  months 
after  the  accident. 

I  found  him  to  be  a  well-nourished  man,  not  at  all  anaemic,  but  having 
a  depressed  and  distressed  look.  He  walked  with  a  dragging  of  the  foot 
on  the  paralyzed  side,  in  a  manner  that  was  perfectly  typical  of  hysterical 
hemiplegia.  His  face  was  not  involved  by  either  paralysis  or  spasm. 
The  tongue  turned  slightly  toward  the  left.  The  left  arm  and  leg  were 
nearly  powerless.  He  could  Ilex,  extend,  pronate,  and  supinate  the  fore- 
arm and  hand,  but  his  upper  arm  was  weaker ;  he  could  only  j^artly  con- 
tract the  biceps  and  could  barely  raise  the  arm  out  from  his  side  a  few 
inches.  He  could  not  keep  the  arm  up  when  held.  He  showed  the  same 
general  weakness  in  the  leg,  though  this  was  relativel}^  less  paralyzed. 
He  could  stand  and  drag  the  leg  along ;  he  could  extend  and  flex  the  foot ; 
he  could  do  all  movements,  though  feebly.  The  paralysis  of  both  arm 
and  leg  was  of  the  flaccid  type,  and  there  was  no  rigidity  or  spasm.  The 
knee-jerks  were  normal  on  the  left,  somewhat  exaggerated  on  the  right ; 
the  elbow-jerks  the  same.  The  arm  was  affected  with  a  marked  tremor, 
which  was  coarse  in  character,  and  did  not  increase  with  voluntary  move- 
ment, but  continued  active.  On  resting  the  arm  the  tremor  ceased.  He 
could  carry  a  glass  of  water  to  his  mouth.  There  was  more  tremor  in 
the  right  arm  than  in  the  left.  There  was  a  very  decided  antero-pos- 
terior  oscillation  or  tremor  of  the  head;  this  was  lessened  and  almost 
stopped  b}^  taking  hold  of  the  head  with  the  hands  and  pulUng  upward. 
There  was  no  notable  tremor  of  the  legs.  There  was  some  cutaneous 
anaesthesia  on  the  left  side,  involving  especially  the  arm,  the  shoulder, 
upper  part  of  the  trunk,  and  to  a  less  extent  the  leg.  The  face  was  not 
involved.  There  was  no  ataxia.  There  was  a  vasomotor  paresis  of  the 
left  hand  and  arm,  which  were  reddened  and  felt  colder  than  the  right. 
There  was  a  slight  atrophy  of  the  left  arm,  the  left  forearm  measui'ing 
8i|,  the  right  forearm  9 J  inches.  The  electrical  reactions  showed  a  slight 
lessening  of  galvanic  and  faradic  irritability.  Electric  sensibility  was 
lessened  in  the  left  arm. 

The  pupils  were  normal  in  reaction,  and  not  dilated.  Some  visual 
weakness  in  the  left  ej^e ;  concentric  limitation  of  the  visual  field ;  no  re- 
versal of  the  color  fields,  but  the  green  field  was  very  much  contracted. 

The  ears  showed  a  loss  of  hearing  to  high  notes,  especially  in  the  left 
ear,  with  a  lessening  of  bone  conduction  in  that  ear. 

There  was  impairment  of  taste  on  both  sides  and  a  loss  of  smell  on 
the  left  side,  also  an  anaesthesia  of  the  nasal  mucous  membrane,  although 
there  was  no  evidence  of  anaesthesia  of  the  cutaneous  surface  of  the  face. 

The  patient  was  a  nuin  of  fair  intelligence.  He  was  suffeiing  a  good 
deal  from  pain  in  the  head  and  mental  depression,  and  from  the  incon- 
venience of  his  tremor  and  paralysis.  He  had  no  con\'ulsive  attacks  or 
crises  of  any  kind  after  the  first  week  following  the  accident. 

The  case  was  settled  out  of  court  and  lost  sight  of  by  me. 


350  ^   SYSTEM  OF  LEGAL   MEDICINE. 


Case  III. 

Traumatic   Hysteria   in   a   Woman-cataleptic. — K.  C,  female;    aged 

tweuty-two,  single ;  nativity  and  parentage,  American ;  occupation,  sales- 
woman. Family  liistoiy  absolutely  negative,  parents  and  brothers  and 
.sisters  were  all  healthy.  The  patient  used  to  be  a  well,  strong,  and 
healthy  girl,  said  not  to  have  been  of  a  nervous  temperament.  She 
had  done  her  work  regularly  as  saleswoman  for  several  years,  and  was 
intelligent  and  competent.  On  December  11,  1892,  she  was  struck  on 
the  top  of  her  head  by  an  iron  instrument  which  fell  from  a  shelf  upon, 
her.  It  knocked  her  down  and  she  was  made  senseless,  and  shortly 
after  went  into  convulsions  the  character  of  which  I  do  not  know.  She 
was  revived  and  walked  home  two  hours  later.  There  was  a  cut  found 
upon  the  head  when  she  was  examined  by  the  physician  that  day.  She 
went  to  bed  and  slept  that  night,  and  stayed  at  home  for  the  next  three 
days,  suffering  from  headache  and  loss  of  appetite.  Then  she  went  to 
work,  but  suffered  continually  from  headache,  loss  of  appetite,  and  a 
feeling  of  weariness  and  exhaustion.  At  times  she  had  to  go  home 
from  her  work  before  the  day  was  over.  She  menstruated  regularly. 
She  gradually  lost  flesh,  but  kept  up  her  work  until  the  early  part 
of  March,  1893,  three  months  after  the  accident.  She  then  had  an  at- 
tack of  convulsions  again,  without  any  known  cause.  There  had  been 
meanwhile  no  attempts  at  litigation  on  her  part.  The  convulsions  con- 
tinued daily  after  this  time ;  she  would  have  them  several  times  in  the 
course  of  the  twenty-four  hours.  She  woidd  fall  back  on  the  bed  appar- 
ently unconscious  and  become  perfectly  rigid,  then  she  would  go  through 
various  coordinated  but  irregular  convulsive  movements.  She  sometimes 
did  not  lose  consciousness,  so  she  said ;  at  other  times  she  did.  I  had  an 
opportunity  of  examining  her  in  one  of  these  states  of  unconsciousness 
with  rigidity,  about  a  month  after  the  convulsions  began.  I  made  the 
diagnosis  of  traumatic  hysteria,  prescribed  for  her  some  valerianate  of 
zinc  with  tonics,  and  advised,  if  possible,  a  removal  from  home.  After 
my  visit  the  attacks  became  somewhat  lighter  and  consisted  simply  of 
f  ainting-spells,  during  which  she  became  unconscious  and  somewhat  rigid 
for  about  half  an  hour.  She  would  have  several  of  these  weekly.  Dur- 
ing the  next  six  months  these  attacks  grew  still  lighter  and  more  infre- 
quent. The  patient  gained  some  strength,  though  she  was  still  weak 
and  pale,  and  in  aU  respects  unlike  herself.  Examined  by  me  at  this 
time,  nearly  nine  months  after  the  original  injury,  I  found  that  she  had 
no  paralyses,  no  tremor — in  fact,  no  special  motor-disturbance  except  a 
general  weakness.  There  was  some  exaggeration  of  the  knee-jerks,  how- 
ever, and  of  the  elbow-jerks.  There  was  no  cutaneous  or  muscular  an- 
assthesia.  Examination  showed  a  very  decided  concentric  limitation  of 
the  visual  fields.  This  was  almost  equally  marked  for  all  colors  in  the 
right  eye,  but  only  a  limitation  by  the  rule  for  all  colors  in  the  left  eye. 
There  was  no  loss  of  color  sense  and  no  reversal  of  the  blue  and  red 
fields  in  either  eye.  The  vision  of  the  right  eye  was  somewhat  weaker, 
apart  from  limitation  of  the  field,  and  she  had  decided  anaesthesia  of  the 
right  nostril  both  to  ammonia  and  to  odors.  There  was  also  some 
pharyngeal  anaesthesia  and  some  disturbance  of  taste  on  the  right  side 
of  the  tongue,  so  that  bitter  was  tasted  as  salt.     The  hearing  in  both  ears 


THE   TRAUMATIC  NEUROSES.  ;Jol 

was  good  as  to  range  and  conduction  and  acuity.     The  patient  has  con- 
tinued to  improve,  and  I  have  since  lost  sight  of  her. 

Prognosis. — It  is  difficult  to  make  a  general  statement  with  regard  to 
the  prognosis  of  traumatic  hysteria.  There  are  cases  which  are  well  in 
a  few  weeks  from  the  onset  of  the  symptoms;  there  are  others  in  which 
the  disease  lasts  for  three  or  four  years,  and  I  have  known  cases  in  which 
the  duration  was  very  much  longer.  Charcot  gives  a  rather  unfavoraljle 
prognosis  for  cases  of  hysteria  major  where  the  symptoms  have  become 
fixed,  whether  this  be  of  traumatic  or  other  origin.  Thorbm-n  speaks 
more  hopefully  of  such  cases,  and  believes  that  if  they  are  treated  promptly 
and  if  there  is  no  complicating  element  of  physical  injury  or  litigation, 
patients  ought  to  get  well  in  a  few  months  at  least.  My  own  experience 
is  that  in  traumatic  cases  the  patients  may  all  be  said  in  a  general  way 
to  be  curable,  but  that  even  under  good  conditions  they  may  suffer  for 
several  years  aud  are  liable  to  a  relapse  after  recovery  has  taken  place. 
There  are  many  cases,  however,  in  which  complete  recovery  has  taken 
place  within  a  few  months.  There  is  no  doubt  that  the  fact  of  a  Htiga- 
tion  and  the  prospect  of  damages  influence  markedly  the  prognosis,  and 
few  patients,  even  though  they  be  perfectly  honest,  get  well  while  the 
anxiety  of  a  trial  weighs  upon  them.  The  coexistence  of  a  physical  in- 
jury, such  as  a  severe  sprain  or  an  injury  to  a  nerve  or  a  bad  contusion 
of  the  head,  makes  the  prognosis  less  favorable.  The  prognosis  is  less 
favorable  in  middle-aged  males  than  in  young  men,  and  it  is  usually  more 
favorable  in  women  than  in  men.  The  presence  of  chronic  alcoholism, 
of  sexual  abuse,  of  a  decided  neurotic  tendency,  all  make  the  prognosis 
less  favorable.  The  marked  fluctuation  in  the  symptoms,  such  as  trans- 
ference of  the  aucPsthesia  or  partial  disa^^pearance  of  it  under  metals, 
makes  the  prognosis  more  favorable.  Finally,  it  must  be  remembered 
that  severe  types  of  hysteria  major  appear  in  rare  instances  to  be  asso- 
ciated with  the  development  of  organic  changes  in  the  nervous  centers. 

Pathology. — The  prevalent  view  with  regard  to  the  nature  of  major 
hysteria  is  that  which  has  been  so  carefully  elaborated  by  Charcot.  This 
is  to  the  effect  that  through  the  influence  of  the  nervous  shock  the  patient 
becomes  to  a  certain  extent  self -hypnotized,  and  as  a  result  of  this  has 
paralysis  which  is  strictly  comparable  with  that  artificially  produced  by 
hypnotism ;  in  other  words,  traumatic  hysteria  major  is  a  condition  of 
auto-suggestion  in  wliicli  the  antesthesia,  paralysis,  tremors,  contraction 
of  the  visual  field,  aud  other  symptoms  are  the  result  of  a  violent  excite- 
ment of  the  imagination,  with  an  accompaupug  loss  of  volitional  aud 
inhibitory  power.  Reduced  to  non-teclinical  language,  this  theory  is 
that  traumatic  hysteria  is  all  a  fancy.  Such  view  is  entirely  insufficient, 
in  my  opinion,  to  explain  the  symptomatology  of  the  disease.  No  person 
who  had  not  received  some  pi-evious  suggestion  could  by  any  exercise  of 
his  imagination  think  himself  suffering  from  loss  of  smell,  taste,  vision, 
hearing,  and  tactile  sense  on  one  side  of  the  body  alone,  for  such  complex 
of  symptoms  is  entu-ely  unknown  to  the  laity.  There  must  be,  therefore, 
something  more  than  this  postulated  in  order  to  explain  these  curious 
phenomena.  This  further  element  in  the  theory  of  the  condition  is  as- 
sumed by  others  to  be  a  vascular  spasm,  it  being  thought  that  liy  the 
influence  of  a  nervous  shock  there  can  be  produced  a  spasm  of  certain 
vascular  areas  which  nourish  the  posterior  parts  of  the  internal  capsule 


332  ^   SYSTEM  OF  LEGAL  MEDICINE. 

and  perhaps  the  sensori-motor  areas  of  one  side  of  the  brain.  Dr.  Bas- 
tian  seems  to  think  that  the  vascular  theor}^  is  the  essential  and  perhaps 
the  efficient  one.  For  my  own  part,  it  seems  to  me  we  are  at  present 
quite  nnable  to  explain  the  phenomena  of  major  hysteria  with  any  degree 
of  satisfaction. 

So  far  as  the  pathological  anatomy  is  concerned,  we  stand  upon  a 
firmer  ground.  It  seems  almost  incredible  when  one  sees  these  severer 
types  of  hysteria  that  there  should  not  be  some  organic  change  under- 
l^dng  it.  The  fact  that  there  is  no  such  change,  however,  has  been  dem- 
onstrated :  first,  by  the  histories  of  cases  in  which  sudden  cure  has  taken 
place  even  when  the  paralysis  and  aueesthesia  were  most  complete ;  and 
secondly,  post-mortems  by  Pell,  Oppenheim,  and  others  on  eases  of  trau- 
matic h3^steria  have  demonstrated  that  there  are  no  lesions  appreciable 
to  the  naked  eye  or  through  ordinary  microscopical  research. 


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1815.  (2)  Boyer,  "Maladies  Cliirui'gicales,"  vol.  iii.,  p.  135.     Two  cases  of  concus- 

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3Iitclii:ll,  iS.   Il'cir,  "Diseases  and  Injuries  of  Nerves."     1872. 

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irHlii/k,  A.,  " Anatoniisehcn-  Befund  nach  Ilirnscliiitteruiig."  "Viertel- 
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Leijdcu,  K.,  "Klinik  der  Riiekenmarkkr.,"  Book  ii. 

Far/et,  Sir  James,  "  Clinical  Lectiu-es  and  Essays."     Neuromimesis. 

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Jirh,  "Concussion  of  the  Spinal  Cord."  Ziemssen's  Cyclopaadia,  vol.  xiii., 
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letzung  auf  Eisenbahn."  "Charite-Annalen,"  1878.  Three  eases  of 
railway  spine  thought  to  be  due  to  minute  hemorrhages. 

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Hysterical  Phenomena."     "Progr.  Med.,"  May  3d. 

Foiirnier,  Prosper,  "Traumatism  and  Rheumatism."     Thesis,  Paris,  1878. 

Bigler,  G.,  "Ueber  die  Folgen  der  A^erletz.  auf  Eisenbahneu."     Berlin. 

Ubersteiner,  H.,  " Ueber  Erschiitterung.  des  Riickenmarks."  "Med.  Jahi-- 
bik'her,"  p.  531. 

BoscntltaJ,  upon  "Latent  Brain  Trauma."     "Wien.  Med.  Blatt,"  1879. 

GucrtDonprez,  "Simulation  des  Douleurs  Consecutives  au  Traumatisme." 
Lille,  1880. 

Shaffer,  X.  M.,  "The  Hysterical  Element  in  Orthoptedie  Surgery."  New 
York,  1880. 

Siegfrit;:,  "Our  Knowledge  of  Railway  Spine." 

Jordan,  F.,  "Hastings  Essav  on  Shock."  "  Sui'gieal  Inquiries,"  London, 
1880. 

Baricell,  "Treatise  on  Diseases  of  Joints."  London.  "Hj-steric  Pseudo- 
disease  of  Joints." 

DUtscke,  C,  "  Essaj'  on  the  Diagnosis  of  the  Injuries  and  Concussion  Sj-mp- 
toms  following  Railway  Accidents."     "Inaug.  Dissert.,"  Berlin,  1881. 

Lauder,  Briiiiton,  "Shock  and  Sj-ncope." 

ManseU-MouUin,  "International  Encyclopaedia  of  Surgery,"  vol.  i.,  p.  369. 
On  "Shock." 

MoeU,  C,  "  Ueber  psychische  Storungen  nach Eisenbahmmf alien."  "Ber- 
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Hodges,  R.  M.,  on  "  So-called  Concussion  of  the  Spinal  Cord."  "Boston 
Med.  and  Surg.  Jour.,"  Api-il  21st  and  28th. 

Pel,  "Notes  on  Fright  Paralysis."     "Berl.  Klin.  Woch.,"  1881. 

Coin-fade,  A.,  "Spasm  of  the  CEsophagus  consecutive  to  a  Traumatism." 
"Union  Med.,"  Paris,  1882,  third  s'eries,  vol.  xxxiv.,  p.  603. 

Henoch,  E.,  "  Cerebral  S^nnptoms  after  Trauma."  "  Char.  Annal.,"  Berlin, 
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Walton,  G.  L.,  "Boston  Med.  and  Surg.  Joxir.,"  October  11th.  "Hysteria 
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354  ^  STSTEM  OF  LEGAL  MEDICINE. 

1884.     (58)  Eeyndlds,  "Loss  of  Taste  and  Smell  in  consequence  of  a  Fall."     "Cincin- 

nati  Lancet  and  Clinic,"  1884,  p.  423. 
1884.     (59)  MiiUer,  F.  C,  "Eailway  Spine." 
1884.     (60)  Putnam,  J.  J.,   "Eecent  Investigations  into  the  Pathology  of  so-called 

Concussion  of  the  Spine,"  etc.      "Boston  Med.  and  Surg.  Join-.,"  1883 ; 

"Amer.  Jour,  of  Neur.  and  Psych.,"  1884.     Hysteria  and  trauma. 
1884.     (61)  Thomsen,  E.,  u.  Oppeitlieim,  H.,  "  Ueber  das  A^orkommen  u.  die  Bedentung 

der  sensor.  Anassthesie  bei  Erki'ankungen  des  Centralen  Nervensyst." 

"  Archiv.  f.  Psych,  u.  Nerv.,"  vol.  xv.,  pp.  559,  633 ;  vol.  x\t..,  "Berlin. 

Klin.  Woeh.,"  No.  15. 
1884.     (62)  Edmunds,  "  Concussion  and  Inflammation  of  Spinal  Cord,  from  Gunshot 

Wound  of  Back  ;  Brain,"  April,  1884. 
1884.     (63)  Preston,  C.  H.,  "Concussion  of  the  Spinal  Cord."     Case  from  being  tossed 

in  a  blanket.     "Iowa  Medical  Reporter,"  July,  1884. 
1884.     (64)  Dana,  C.  L.,  "Concussion  of  the  Spine  and  its  Relation  to  Ne myasthenia 

and  Hysteria."     "Medical  Record,"  December  6th. 
1884.     (65)   Crotliers,  T.  D.,  "Inebriety  coming  from  Injuries  of  the  Head  and  Body."' 

"Med.  News,"  vol.  xliv.,  pp.  204-207. 
1884.     (66)  Johnson,  J.  G.,  "Concussion  of  the  Spine  in  Railway  Injuries."     "Med. 

Legal  Jour." 

1884.  (67)  Matliea-s,  "Sui'geon's  Duty  in  Railroad  Spinal  Injuries."     "  St.  Louis  Med. 

and  Surg.  Jour.,"  September. 

1885.  (68)  Terrillon,  "Hysterical  Disorders  of  Motion  and  Sensation  after  Injury."' 

"Bull.  Soe.  de  Chirur.  de  Paris,"  1885,  vol.  xi.,  p.  378. 

1885.  (69)  Kalliefe,  "Concussion  of  the  Spine  after  Railway  Accidents."  "Inaug^. 
Dissert.,"  Breslau,  1885. 

1885.     (70)  Seiffert,  O.,  "Notes  on  the  Neuroses  following  Injimes  and  Concussion." 

1885.  (71)  Groenigen,  "Ueber  den  Shock."  Wiesbaden.  "Historical  and  Critical 
Review." 

1885.  (72)  Mitchell,  Weir,  "Hysterical  Paralyses,  Contractm-es,  and  Ai-thi-algias."' 
"Nervous  Diseases,"  Philadelphia,  1885. 

1885.  (73)  Page,  H.  W.,  on  "Abuse  of  Bromide  of  Potas.  in  the  Treatment  of  Trau- 
matic Neurasthenia."     "Medical  Times  and  Gazette,"  April  4,  1885. 

1885.  (74)  Oppenhcim,  H.,  "Weitere  Mittheilungen  iiber  die  sieh  am  Kopfverletz- 
ungen  u.  Ersehiitterungen  (in  specie  Eisenbahnunfalle)  Erkrank.  des 
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1885.  (75)  Dumcnil  and  Fetet,  "Commotio  de  la  Moelle  Epiniere."  "Archives  de- 
Neurologic,"  January,  March,  May. 

1885.  (76)  Begue,  upon  "Traumatic  Spasm  following  Incomplete  Destruction  (deehi- 
vure)  of  Nerves."     Thesis,  Paris,  1885. 

1885.  (77)  Fauvel,  H.,  "Traiimatic  Paralyses  of  Peripheral  Origin."     Thesis,  Paris.. 

1886.  (78)  Bock,  W.,  "Symptomatology  of  Railway  Spine." 

1886.  (79)  i»«<po«c7;e/,  "Hysteric dans I'Armee."  "Rev.  Med.,"  June,  1886.  Hyster- 
ical paralyses. 

1886.     (80)   Quinqueton,  "Hystevia  in  Man."     Thesis,  Paris. 

1886.  (81)  Lomhroso,  "Diagnosis  and  Treatment  of  Hystero-Traiunatie  Accidents."' 
"Lo  Sperimental,"  December,  1886. 

1886.  (82)  Hunt,  TTm.,  "Concussion  of  Brain  and  Spinal  Cord."  "Pepper's  System 
of  Medicine,"  vol.  v.,  p.  907.     Dealing  with  concussion  and  shock. 

1886.     (83)   Westphal,  "Arch.  f.  Psychiatric,"  vol.  xvii.,  p.  282. 

1886.  (84)  Pompon,  R.,  "Paralyses  Hystero-Traumatiques."  "L'Encephale,"  Jan- 
uary. 

1886.  (85)  Burkhardt,  "Contribution  to  the  Study  of  Traumatic  Hysteria."  "Rev. 
Med.  de  la  Suisse  Romande." 

1886.     (86)   Onimus,  " Paralysis  after  Railroad  Accidents."     "  Union  Med.,"  June  6th. 

1886.     (87)  Renard,  G.,  "Hystero-Traumatic  Contracture."     Thesis,  Paris. 

1886.  (88)   Vaudier,  "  Paralysis  Agitans  after  Traumatism."     Thesis,  Paris,  1886. 

1887.  (89)  Charcot,  "  Lemons  sur  les  Maladies  du  Syst.-Nerv.,"  chapters  iii.,  vii.,  viii.^ 

ix.,  xviii.,  sqq.     Hysteria   and  traumatism.       "Progr.   Med.,"  Nos. 

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1887.     (90)  ^o-kc.  P.,  "Hysteric  et  Traumatisme."     Paris.     Also  "Soe.  Clin.,"  May 

28th;  also  "Gaz.  des  Hopitaux,"  August  6th. 
1887.     (91)  Bataille,  "Traumatism  and  Neuropathy."     Thesis,  Paris,  1887. 
1887.     (92)  Bergmann,  Josrf,  "Neuroses  following  Psychical  Excitement  (shock)." 

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1888.  (116)  StrihnpeU,  A.,  "Ueber  die  Traumatisehe  Neurosen."  "Berlin.  Klin. 
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356  -^   SYSTIJM  OF  LEGAL  MEDICINE. 

1888. 


1888. 

1888. 
1888. 

1889. 
1889. 
1889. 
1889. 
1889. 
1889. 
1889. 
1889. 
1889. 

1889. 

1889. 

1889. 

1889. 

1889. 

1889. 
1889. 

1889. 

1889. 

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127)  Thermes,  G.,  "Hystero-Traumatism."     "Bull.  Soc.  de  Med.  Prat.,"  Paris, 

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128)  Bongier,  M.,  "Contribution  to  the  Study  of  Hystero-Traumatism."     4to, 

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129)  Sciamanna,  E.,  "Traumatic  Hysteria."     "Rev.  Gen.  Ital.  di  Clin.  Med.," 

Pisa,  1889-90,  vol.  i.,  p.  249. 

130)  ZwaardemaJcer,  "  Traumatic  Neuroses."     "Nederl.mil.  geneesk.  Arch.  Ut- 

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136)  Sioearingen,  R.  M.,  "Railway  Corporations  and  their  Duty  to  Persons  In- 

jured."    "Daniel's  Tex.  Med.  Jour.,"  vol.  iv.,  p.  185. 

137)  Walton,  G.  L.,  "Boston  Med.  and  Sm-g.  Jour.,"  December  19,  1889.     Simu- 

lation. 

138)  Knapp,   P.   C,   "Boston  Med.   and   Surg.   Jour.,"  December  19th-26th. 

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139)  Oj>penheim,  H.,  "Die  Trauvi.'Neui'osen."  Hirschwald,  Berlin.   Also"Neu- 

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141)  Briins,  L.,  "  Kasuistik  der  Traumat.  Neuroses  Nerv.-Centi'albl."     Case  of 

traumatic  hysteria  from  slight  injury. 

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143)  Dutd,  "Gaz.  Med.de  Paris,"  November  30th.     Traumatic  and  non-trau- 

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148)  Smith,  H.  H.,  "Case  of  Malingering."     "Journal  of  American  Med.  Asso- 

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149)  Watson,  Penrose,  "Malingering."     "Jour.  Amer.  Med.  Assoc,"  August, 

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150)  Jndd,  "Malingering."     "Jour.  Amer.  Med.  Assoc,"  February  22d. 

151)  Wichmann,  "Berlin.  Klin.  Woch.,"  July  1,  1889.     "Malingering." 

152)  Meyer,  M.,   "Berlin.   Klin.   Woch.,"  February  4,   1889.      "Neurasthenia 

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langen,  1889. 


liiiiLioanAriiY. 


557 


1889. 

1889. 

1889. 

1889. 
1889. 

1889. 
1890. 

1890. 

1890. 

1890. 

1890. 

1890. 

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1890. 

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(156 
(157 

(158 

(159 
(KiO 

(IGl 
(1G2 

(1G3 

(104 

(1G5 

(16G 

(167 

(168 

(169 

(170 
(171 

(172 
(173 
(174 
(175 
(176 
(177 
(178 
(179 


1890.   (180 


1890. 

(181) 

1890. 

(182 

1890. 

(183 

1890. 

(184) 

1890. 

(185 

1890. 

(186 

1890. 
1S90. 

(187 
(188 

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Case  oansed  by  fri<^lit  alone. 

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The  case  lja,(l  had  tabes.     "Berlin.  Klin.  Woch.,"  No.  18,  18^9. 

Jacdhi/,  (}.  If'.,  "Notes  on  Trauniatie  Hysteria.  Classification."  "N.  Y. 
Mod.  Monatschr.,"  vol.  i.,  No.  2,  1H89. 

Prince,  M.,  Boston  Med.  and  Surg.  Jour.,"  December  12th.     Two  cases. 

Eincnlnhr,  "Berlin.  Klin.  Woch.,"  December  30th.  Critical,  classifi- 
cation. 

Clevenger,  S.  V.,  "Spinal  Concussion."     8vo,  F.  A.  Davis.     Philadelphia. 

Cosserat,  "Contribution  to  the  Study  of  Hystero-Traumatism."  4to, 
Nancy,  1890,  Thesis. 

Greidoibcni,  I'.  S.,  on  "Traumatic  Neuroses."  "Protok.  Zasaid  Tavrus 
Med.  Pharm.,"  1890,  vol.  i.,  p.  67.     Russian. 

Krieqc,  "  Vasomotor  Disturbances  of  the  Skin  in  Traumatic  Neuroses." 
"Archiv.  f.  Psych.,"  1890,  vol.  xxii.,  p.  241. 

Bonier,  A  case  of  traumatic  neurosis.  "Vereinsbl.  f.  pfiilz.  Aertze.," 
1890,  vol.  vi.,  p.  28. 

Bitter,  "  Contribution  to  the  Study  of  the  Traumatic  Neuroses."  "Berlin. 
Klin.  Woch.,"  1890,  vol.  xxvii.,  p.  361. 

Hoffmanv,  J.,  "  Berlin.  Klin.  Wochenschr.,"  Jidy  21st.  Twenty-four  cases, 
eight  fraudulent. 

Schultze,  F.,  "Samml.  Klin.  Vortrage,"  No.  14.  Simulation.  "New  Re- 
sults." 

Seeliymiiller,  "Deut.  Med.  Wochenschr.,"  July  24th,  October  23d,  30th, 
Simulation. 

Mendel,  E.,  "Verhandl.  des  X.  Internat.  Med.  CoTig.,"  Bd.  iv.,  Abth.  14. 

Friedmann,  M.,  upon  "A  Specially  Severe  Forju  of  Trouble  following 
Brain  Concussion."  "Arch.  f.  Psych.,"  Bd.  xxiii.,  Hft.  1.  Vasomo- 
tor symptom  complex,  post-mortem  given.     See  1891. 

Bernhardt  and  Krouth(d,  "Neurol.  Centralbl.,"  1890,  p.  103.  Case  of  so- 
called  traumatic  neurosis,  with  autopsy. 

GutJi,  "Diagnostic  Value  of  some  Symptoms  of  the  Traumatic  Nem-oses." 
"Inaug.  Dissert.,"  Bei'lin.     C  Schade. 

Mobiiis,  r.  S.,  "  Notes  upon  Simulation  in  Traumatic  Nervous  Affections." 
"Miinchen  Med.  Woch.,"  No.  50,  and  1891,  No.  39. 

Btinipf,  "  The  Critical  Symptomatology  of  the  Traumatic  Neuroses  "  (com- 
motio cerebro-spinalis).     "Deut.  Med.  Woch.,"  No.  9. 

Kroiifcid,  a  case  of  traumatic  hj^steria.  "Wien.  Med.  Wochen.,"  No.  17, 
1890. 

Tliiess,  C,  " Our  Knowledge  of  the  Traumatic  Neiu-oses."  "Inaug.  Dis- 
sert.," Gottingen,  1890. 

Harrison,  C.  L.,  an  unusual  case  of  shock  following  concussion  of  the 
lumbar  spine.     "Med.  Record,"  December  6,  1890. 

Sch)U(((its,  "Remarks  on  the  Pathological  Anatomy  of  Spinal  Concussion." 
"Arch.  f.  Path.  Anatomic,"  Bd.  cxxii.,  1890.  Three  autopsies,  and  ex- 
periments 071  dogs. 

Kleiiiperer,  F.,  "Traumatic  Tabes."  "Zeitseh.  f.  Klin.  Med.,"  vol.  xvii.. 
1890.  Also  Wichma)},  "  Value  of  the  Sjanptoms  of  Traumatic  Neuroses." 
Braunschweig,  1892,  p.  66. 

Ledcier,  " Twelve  Cases  of  Traumatic  Neuroses,  "with  Special  Reference  to 
New  Objective  Symptoms." 

Walton,  <r.  L.,  study  of  symptoms  in  100  cases.  Seventeen  percent.  Lemi- 
anpesthetic.  Difference  in  calves  never  over  five  eighths  of  an  inch. 
"Jour,  of  Nervous  and  Mental  Diseases,"  July,  1891. 

Savill,  two  neuropathic  cases,  traumatic  and  non-traumatic.  "  St. Thomas's 
Hosp.  Reports,"  vol.  xviii. 

Bremer,  "Cincinnati  Med.  News,"  February,  1890.  "Traum.  Hysteria," 
March. 

Brunelli,  "  Refornia  Medica."  Naples,  July  1st.  Traumatic  hysteria  ease. 
Very  rare  in  Italy. 

Clevenger,  "Boston  Med.  and  Surg.  Jour.,"  September  4th.  "Erichsen's 
Disease." 

TYacnkel,  "Inter.  Klin.  Rund,"  Jidy  20th.     Simulation. 

Knaj^p,  "Boston  Med.  and  Surg.  Jour.,"  December  26th.     Simulation. 


358  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

1890.   (189)  Do?i«i/i,  "Wien.  Med.  Wocli.,"  September  27th.     Simulation  rare. 
1890.  (190)  Barbour,  J.  F.,  two  cases  of  traumatic  neuroses.     "Progress,"  vol.  iv.^ 
p.  697,  1890. 

1890.  (191)  Bobrol)',  A.  A.,  "Traumatic  Tropho-Neuroses  of  the  Lower  Extremities." 

"Laitop.  Khirurg.  Obsch.  v.  Mosk.,"  1890,  vol.  ix.,  p.  260. 

1891.  (192)  Hermann,  O.,  "Notes  on  the  Traumatic  Neuroses."     Wm-zburg,  8vo,  1891. 

Thesis. 
1891.   (193)  Selenski,  "Case  of  Traumatic  Neuroses  in  a  Child."     "Meditsina,"  St.  Pe- 

tersi)uj*g,  1891,  vol.  iii.,  p.  60. 
1891.   (194)  Stephan,  "Nervous  Disturbances  after  Trauma."     "Nederl.  Tijdschr.  V 

Gen.,"  vol.  xxvii.,  p.  625. 
1891.   (195)   Cartex,  A.,  "Traumatism  and  Neuropathy."  '  "Med.  Mod.,"  Paris,  1891, 

vol.  ii.,  p.  117. 
1891.   (196)  Cullerre,  A.,   "Neuroses  Consecutive  to  Accidents."      "Ann.  Med.  Psy- 

cholog.,"  Paris,  1891,  vol.  xiii.,  p.  261. 
1891.   (197)  Behove  and  Eemo)td,  " Hystero-Traumatic  Accidents  following  Sudden  In- 
jury."    "Bull.  Soc.  Med.  de  Hop.  de  Paris,"  1891,  vol.  viii.,  p.  273. 
1891.  (198)   Wolff,  B.,  "Neurasthenia  Cerebralis  Traumatica." 
1891.  (199)  Dunin,  Th.,  " Some  Notes  on  the  so-called  Traumatic  Neuroses."     "Dent. 

Arch.  f.  Klin.  Med.,"  Bd.  Ixvii.,  p.  532. 
1891.   (200)  Brainerd,   "Medical  Standard,"  March,  1891.     Experiments  on  dogs  by 

Watson. 
1891.  (201)  Hun,  "Traumatic  Hysteria."     "N.  Y.  Med.  Jom-.,"  February  7,  1891. 
1891.   (202)  Putnam,  "Buffalo  Med.  and  Sui-g.  Jour.,"  October,  1891.     Three  cases  of 

traumatic  hysteria  cured. 
1891.  (203)  Derciim,  "N.  Y.  Med.  Jour.,"  June  6,  1891.      Litigation   symptoms   and 

prognosis. 
1891.   (204)  Freimd,  C.  S.,  and  Kayser,  S.,  "Ein  Fall  von  Sehreckneurosen  mit  Gehors- 

anomalien."     "Deut.  Med.  Woehen.,"  No.  31. 
1891.   (205)  Freund,  C.  S.,  "Demonstration  Einiger  Falle  von  sog.  traum.  Neurose." 

"Centralbl.  f.  Nervenheilk.  tmd  Psych.,"  July,  1891. 
1891.   (206)  jRoi/;,  four  cases  of  traumatic  neuroses,  with  notes  upon  the  same.     "Ber- 
lin. Klin.  Wochenschr.,"  No.  9. 
1891.   (207)  SeeUgmilUer,  "Further  Notes  on  the  Traumatic  Neuroses  and  the  Question 

of  Simulation."     "Deut.  Med.  Woeh.,"  Nos.  31,  32,  33,  34. 
1891.   (208)  Buhois,    "The   Traumatic   Neuroses."      " Correspondsbl.    f.    Schweitzer 

Aerzt,"  No.  17,  1891,  p.  530. 
1891.   (209)  <S'ene«a;,  P.,  "Arch,  de  Neurol.,"vol.  xxii.,  p.  48,  1891.     Hystero-traumatic 

paralysis  ;  loss  of  faradic  excitability. 
1891.   (210)  Bercwm.,  "The  Back  in  Eailway  Spine."     "Jour,  of  Nervous  and  Mental 

Diseases,"  July,  1892. 
1891.   (211)  SepeUi,  "Eevista  Sperimenta  di  Frenat.,"  January  11,  1891.     Review. 
1891.   (212)  Sclmltze,  Fr.,   "Deut.  Med.  Woch.,"  July  2,  1891.      "Visual  Fields  and 

Angesthesia."     Also  "Miinch.  Med.  Woch.,"  June  9th. 
1891.   (213)  Hitzig,  "Deut.  Med.  Woch.,"  July  30,  1891.     Controversial. 
1891.   (214)  Collins,  Joseph,,  "Journal  of  Nervous  and  Mental  Diseases,"  November,. 

1891.     Truamatie  hysteria.     A  case  cured  by  hypnotism. 
1891.   (215)  Sequin,  "Annual  Univer.  Med.  Sei.,"  vol.  iii.     Simulation. 
1891.   (216)  MdUns,  "Miinch.  Med.  Woch.,"  September  29th. 
1891.   (217)  Hoffmann,  A.,  "Die  traumatische  Neurosen  u.  Unfaffversicherungs  Ge- 

setz."     Volkmann's  "  Vortrage,"  No.  17.     Nature  and  pathology. 
1891.   (218)   Oppenheim,  H.,  "Weitere  Mittheilungen  in  Bezug  auf  die  traum.  Neu- 
roses."    Simulation. 
1891.   (219)  Friedmann,  M.,   "Study  of  the  Sequelee  of  Brain  Concussion."     "Deut. 

Med.  Woch.,"  1891,  No.  39.     Autopsy. 
1891.   (220)  Brnns,  L.,  "Bibliography."     "Schmidt's  Jahrb.,"  1891,  Bd.  ccxxx.,  p.. 81. 
1891.   (221)  Eriege,  "Vasomotor  Disturbances  of  the  Skin  in  Traumatic  Neuroses." 

"Arch.  f.  Psych.,"  vol.  xxii. 
1891.   (222)  Eoniq,  "An  Objective  Symptom  in  the  Traumatic  Neuroses."     "Berlin. 

Klin.  Woch.,"  No.  31,  p.  774,  1891. 
1891.   (223)  Elzholz,  "  The  Traumatic  Neuroses."     "  Wien.  Med.  Presse,"  No.  48,  1891. 
1891.   (224)  Lmmermann,  "A  Case  of  Traumatic  Neurosis."      "Correspon.   Blatt.   f. 

Schw.  Aerzt,"  No.  17,  1891. 
1891.  (225)  Benedict,  "The   Traumatic   Neuroses."      "Wien.  Med.  Presse,"  No.  48,. 

1891. 


niHLiodJLii'UY.  359 

1891.  (22G)  LeweJc,  S.,  "  The  Traumatic  Neuroses." 

1892.  (227)  Kiilnier,  "  Tlie  Traumatic  Neuroses."     "  Viertiljahrsch.  f.  gericht  Med.," 

vol.  iii.,  p.  340. 
1892.  (228)    Wilhrand,   "Cliaiifjes  in  the  "Visual  Field  in  the  Traumatic  Neuroses." 

"Dt'ut.  Med.  Wocli.,"  1892,  vol.  xviii.,  p.  379. 
1892.  (229)  PamtK,  "  The  Oeidar  Stif^nnata  of  Traumatic  Hysteria,"    "  Reforma  Med.," 

Naples,  1892,  vol.  viii.,  p.  531. 
1892.   (230)  Pr/«(V',  J/.,  "  Traumatic  Hysteria.    A  Contribution  to  Prognosis."    "Amer. 

Jour.  Med.  Sci.,"  1892,  vol.  civ.,  p.  63. 
1892.   (231)  EoscinKieli,  "Study  on  Traumatic  Neuroses."      Vrateh,   1892,  vol.  xiii., 

p.  173. 
1892.  (232)  I{of>ciih(tHiii,  G.,  two  cases  of  local  traumatic  neuroses  and  their  course. 

"Therapeutic  Monat.,"  Berlin,  1892. 
1892.  (233)  GiUet  de  Gravdmonf,  "Traumatic  Neurasthenia  and  Ocular  Accidents." 

"Bull.  Soe.  de  Med.  Prat,  de  Paris,"  1892,  p.  244. 
1892.   (234)  Horwit-,   "Neurotic  Ct:deraa  following,'  Trauma."      "Med.  News,"  1892, 

vol.  Ix.,  p.  432. 
1892.   (235)  Li/nidii,  //.  .1/.,  "Traumatic  Paralysis  Agitans."    "Chicago  Clinic  Review," 

1892,  vol.  i.,  p.  42. 
1892.  (236)  Mullier,  "Observations  on  Traumatic  Neurosis."      "Arch.  Med.  Belg.," 

1892,  vol.  xlii.,  p.  242. 
1892.   (237)  Bacli,  J.,  "Klinischer  Beitrag  liber  Traumatic  Hysteria."     8vo,  Breslau, 

1892.     Thesis. 
1892.   (238)  J3erwcn/»,  7!,'.,  "Ueber  Traumatische  Neurosen."    8vo,  Strassburg,  Isted., 

1892.     Thesis. 
1892.  (239)  Buts,  E.,  "Storungen  der  Sensibilitiit  durch  Traumen."     8vo,  Wiirzburg, 

1892.     Thesis. 
1892.  (240)  Bcrnlieim,  "Traumatic  Neurosis  of  the  Nuehge."     "Rev.  Med.  de  I'Est.," 

1S92,  vol.  xxiv.,  p.  489. 
1892.   (241)  Biii-(iir,    " Laryugoscopic   Findings   in   Traimaatic   Neuroses."     "Berlin. 

Klin.  Woeii.,"  1892,  vol.  xxix.,  p.  1197. 
1892.   (242)  EiseuJnhr  and Belnhard,  "Neurolog.  Centralbl.,"  February  15,  1892.    Simu- 
lation. 
1892.  (243)   Oppoilieiiii,  "Die  Traumatisehe  Neurosen."     Second  edition.     Simulation. 

Special  character  and  symjitoms  of  traumatic  neuroses.     "Arch.  f. 

Psj'cli.,"  vol.  XXV.,  p.  248.     Simulation. 
1892.   (244)  Schnlfze,  "Deut.  Zeitseh.  f.  Nervenheilk.,"  vol.  i.,  p.  445.     Simulation. 
1892.   (245)  Frennd,  C.  S.,  "Ein  Ueberlick  ueber  den  gegenwartigen  Stand  der  Frage 

von  den  Sogenannten  traum.  Neuroses."     Volkmann's  "Vortrage." 
1892.  (246)  Dercum,  "  Journal  of  Nervous  and  Mental  Diseases,"  January.     Cases  not 

in  litigation. 
1892.   (247)  Nonne,  A.,  "Deut.  Med.  Woeh.,"  July  7th.     Visual  fields,  etc. 
1892.   (248)  Schmidt-Bimpler,  "Deut.  Med.  Woeh."     Visual  fields,  etc. 
1892.   (249)  Muchfichcr,  "Deut.  Med.  Woeh.,"  April  28th.     Muscular  asthenopia  as  an 

objective  symptom. 
1892.  (250)  Lanoisteiii,  "Deut.  Med.  Woeh.,"  April  14th.      Chloroform  narcosis  for 

simulators. 
1892.   (251)  Bnmpf  gives  three  objective  tests  :  pressure  on  painful  points ;  quanti- 
tative reduction  of  galvanic  irritation ;  faradization  of  nerve-trunk, 

causing  fibrillary  contractions. 
1892.   (252)  A"(?»wfn(H,  J.,  "Inter.  Klin.  Rundschau,"  August  14th.     Case  of  traumatic 

hysteria. 
1892.   (253)  Charcot,  "Clinique  des  Mai.  du  Syst.  Nerv.,"  Tom.  i.,  1892,  pp.  29,  117. 

Hystero-traumatism.     Prognosis. 
1892.  (254)  Benedict,  "Ueber  Hyperaesthesien  der  Kopfknoehen  (Nahtneuralgien)." 

"Internat.  Klin.  Rtrndsehau,"  No.  1. 
1892.   (255)  Friedman)),  upon  a  lieculiar  form  of  sequel  to  brain  concussion  and  the 

vasomotor  sjTnptom  complex  of  it.     "Arch.  f.  Psych.,"  vol.  xxiii. ;  als<? 

"  Neurolog.  Centralbl.,"  April  14,  1892.    Local  neurosis  and  simulation 

question. 
1892.  (256)  Thicm,  C,  "Notes  on  Treatment  and  Care  of  Traumatic  Cases."    Berlin 

1892. 
1892.   (257)   JJ'iclDnann,   on  the  value  of   the  sjnnptoms  of  the  traumatic  neuroses 

Braunschweig,  1892. 
1892.  (258)  Gohhchcidcr,  "Neurolog.  Centralbl.,"  August,  1892.     Tests  of  analgesia 


360 


A  SYSTJEM  OF  LEGAL  MEDICINE. 


1892. 

1892. 

1892. 
1892. 
1892. 
1892. 

1892. 


1893. 

(266; 

1893. 

(267^ 

1893. 

(268, 

1893. 

(269, 

1893. 

(270, 

1893. 

(271] 

1893. 

(272^ 

1893. 

(273] 

1893. 

(274] 

1893. 

(275; 

1893. 

(276; 

1893. 

(277; 

1893. 

(278; 

1893. 

(279; 

1893. 

(280 

1893. 

(281) 

1893. 

(282 

1893. 

(283 

1893. 

(284 

259 

260 

261 
262 
263 
264 

265 


Elzliols,  "Wien.  Klin.  Woeli.,"  February  18tli.  Case  of  traiunatic  -liys- 
teria.     Also  "Wien.  Med.  Doct.  Coll.,"  1891. 

Knapp,  P.  C,  "Boston  Med.  and  Surg.  Jom'.,"  September  1st.  Classifi- 
cation. 

Beard,  Minneapolis.     Review. 

Miclde,  J.,  Brain,  Spring  No.     Effects  of  concussion. 

Coester,  "Berlin.  Klin.  Wocb.,"  No.  31.     Case  of  traumatic  hysteria. 

Hainaut,  M.,  "Nem-ose  Traumatique."  "Arch..  Med.  Beiges,"  October, 
1892. 

Strauss,  A.,  on  the  value  of  Mannkopff's  symptom  in  traumatic  nervous- 
diseases.  "Berlin.  Klin.  Woch.,"  November  28,  1892,  shows  that  it 
and  Rumpfs  symptoms  are  not  always  present. 

Miles,  "Cerebral  Concussion."  "Boston  Med.  and  Surg.  Jonr."  The- 
oretical and  experimental. 

Weill,  E.,  "Slight  Traumatisms  of  the  Head  in  Infants."  "Lyon  Medi- 
cal," November,  1893. 

Knapp,  P.  C,  "Simulation  in  Traumatic  Nervous  Diseases."  "Boston 
Med.  and  Sm-g.  Jom-.,"  September  28,  1893. 

Dubois,  "  Corresj)ond.  fiir  Schweizer  Aerzt,"  September  1st.  Simulation, 
against. 

Strilmpell,  "Neiu'olog.  Centralbl.,"  May  1st.  Text-book,  seventh  edition. 
Simulation. 

Wernicke,  "Neurolog.  Centralbl.,"  May  1st.     Simulation. 

Bremer,  L.,  a  case  of  hysterical  astasia-abasia,  suing  for  damages.  Hys- 
terical paraj)legia.  "  Jom-nal  of  Nervous  and  Mental  Diseases,"  Jan- 
uary, 1893. 

Pel,  "  Traumatic  Hysteria,  with  Autopsy."  "Berlin.  Klin.  Woch.,"  24,  vol. 
XXX.,  June  12,  1893. 

Millard,  Perry  H.,  "Some  Critical  Observations  upon  Certain  Forms  of 
Spinal  Injury."     "Annals  of  Stu'gery,"  1893,  p.  546. 

Bremer,  L.,  "Traumatic  Neuroses  in  Court."  "Medical  Review,"  No- 
vember 11,  1893. 

Outen,  W.  B.,  "  Injuries  to  the  Nervous  System  without  EAn dent  Gross  Le- 
sion."    "Medical  Mirror,"  November,  1893. 

Dana,  C.  L.,  "Text-book  of  Nervous  Diseases."  Article,  Traumatic  Neu- 
roses. 

Beed,  R.  Harvey,  "Railway  Surgery,  its  Present  Status  and  Importance." 
"The  Times  and  Register,"  October  7,  1893. 

Morton,  Thos.  G.,  "Medico-Legal  Exijerieuces  in  Railway  Cases."  "Jour, 
of  Amer.  Med.  Assoc,"  October  7,  1893. 

Wilniaers.  M.,  " Hystero-Epilepsie  Traumatique."  Hypnotism.  "Ai'ch. 
Med.  Beiges,"  1893,  p.  153. 

Blum,  A.,  " Hystero-Neurasthenie  Traumatique."  "Ai-ch.  Gen.  de  Med.," 
1893,  p.  458  sqq.     Critical  review  and  cases. 

Bauer,  L.,  "St.  Louis  Clinique." 

Barlow,  "  Casuistik  zur  Traumatisch.  Neur.  Miinchen."     Lehmann. 

Hochwardt  and  Topolauski,  "  Neur.  Centralbl.,"  1893,  p.  584.  Visual  fields- 
in  traumatic  neuroses. 


INDEX. 


Autopsies  and  Pathology,  23,  127,  139,  147,  166,  173,  194,  213,  268.     See  also  ease 

by  Oppenheim,  of  hysteria. 
Classification,  60,  152,  154,  253. 

Concussion  op  Spine  and  Brain,  3,  5,  7,  8,  9,  10,  27,  50,  59,  78,  89,  105,  155. 
Constitutional  Neuroses  polloaving  Trauma  or  Shock,  84,  276. 
Hysteria,  17,  18,  30,  51,  56,  64,  68,  75,  76,  80,  81,  83,  85,  86,  91,  95,  101,  102,  103,  107, 

110,  119,  120,  122,  123,  124,  129,  135,  137,  138,  140,  152,  156,  170,  178,  179,  189,  195, 

196,  203,  207,  231,  246,  247,  253,  257,  267,  277. 


INDEX.  30  X 

Local  Neuroses  :  («)  Arthralgias,  4,  36,  39,  68,  111 ;  also  in  Oppenheira,  Tr.  Neui-oses., 

casG  31.     (/;)  Paralysis  and  Spasm,  13,  18,  22,  95,  203.     {c)  Vasomotor  Disorders! 

158,  165,  215,  228,  249.     (^0  Other  forms,  17,  25,  30,  46,  191,  226,  234,  235. 
Medico-Legal,  130,  270,  275. 

Org.vnic  Diseases  following  Trauma  and  Shock,  49,  58,  114,  174,  229. 
Prognosis,  21,  44,  90,  153,  196,  197,  208,  224. 
Shock,  19,  26,  38,  41,  42,  67,  141. 
Simulation,  30,  44,  63,  126,  128.  131,  133,  161,  162,  168,  181,  182,  183,  201,  209,  212, 

236,  237,  238,  240,  244,  262,  263,  266. 
Special  Symptoms:  («)  Visual  Disorders,  117,  206,  216,  222,  223,  227,  241,  242,  251. 

(&)    Aural,   118.      (c)    Cutaneous,   233,   252.      {d)    Thi-oat,  235.      (e)  Li  children, 

185,   261. 
Symptoms  and  Diagnosis,  28,  40,  43,  57,  60,  70,  74,  109,  112,  136,  142,  143,  144,  145, 

167,  169,  175,  176,  216,  233,  242,  244,  245,  248,  251,  252,  259. 
Treatment,  141,  208,  250. 


THE  EFFECTS   OF  ELECTRIC   CURRENTS   OF  HIGH 
POWER  UPON  THE   HUMAN  BODY. 

BY 

ALLAN  McLANE  HAMILTON,  M.D.,  and  GEORGE  DE  FOREST  SMITH,  M.D. 


The  utilization  of  electricity  nowadaj'S  is  too  general  and  familiar  to 
need  extended  comment ;  suffice  it  to  say  that  an  agent  that  until  a  (juar- 
ter  of  a  century  ago  was  used  oidy  for  the  operation  of  the  telegraph,  in 
electrometallurgy  and  other  chemical  processes,  and  in  medicine,  to-day 
provides  a  large  part  of  the  motive  power,  light,  and  heat  of  towns  and 
cities  throughout  the  civilized  world,  while  in  our  own  country  the  small- 
est villages  are  equipped  mtli  electric-light  and  street-car  plants,  and 
before  another  decade  is  finished  electricity  is  likely  to  find  its  way  into 
every  household  for  some  economic  purpose. 

Incident  to  its  adoption  it  is  natural  that  the  use  of  so  potent  and 
dangerous  an  agent  should  liave  been  attended  by  accidents  more  or  less 
grave,  due  sometimes  to  want  of  familiarity  upon  the  part  of  those  Avho 
were  engaged  in  providing  it,  or  in  its  application,  and  of  consumers 
who  were  for  the  most  part  entirely  ignorant  of  its  properties  or  manipu- 
lation. These  accidents  have  so  far  not  found  their  way  into  courts  as 
the  basis  of  litigation  except  to.  a  limited  degree,  though  there  is  no 
reason  why  the  responsibilities  of  electric  corporations  differ  from 
others  where  injury  or  death  has  been  the  result  of  negligence.  The  de- 
termination of  cidpability  is,  however,  much  more  difficult,  and  contribu- 
tory negligence  is  naturally  claimed  with  some  reason  Mdiere  the  regula- 
tions and  instructions  are  not  complied  with,  or  where  the  bodily  harm 
is  the  result  of  foolhardiuess  upon  the  part  of  the  injiu'ed  person. 

The  properties  of  electric  currents  should  by  this  time  be  well  enough 
known  to  fix  the  blame  where  it  belongs — either  upon  the  victhn,  the 
power-providing  or  subway  companies,  or  those  who  supply  or  maintain 
imperfect  apparatus  or  poorly  insulated  conductors,  or  exact  dangerous 
services  from  their  employees,  or  in  any  way  expose  others  to  risk  of  life 
or  limb. 

The  mechanical  causation  of  accidents  is  a  subject  that  is  fully  gone 
into  by  writers  upon  electricity,  and  it  is  only  necessai-y  to  say  that  where 
more  or  less  serious  harm  has  resulted  it  has  been  through  imperfect 
conductors  or  insulations,  when  the  person  places  himself  in  the  circuit, 
receiving  a  much  more  powerful  current  than  he  expe(»ted,  or  where  as 
the  result  of  underground  leakage  a  current  of  high  voltage  has  been 
turned  where  it  does  not  belong,  either  traversing  wires  designed  for 

363 


364  -i  systi:ai  of  legal  medicixe. 

ciurents  of  lower  voltage  or  finding  escape  throngli  iron  water  or  gas 
pixies  wliich  the  Adetim  grasps.  Again,  the  i^erson  places  himself  in  the 
cii'cuit  of  a  current  of  gi-eat  amperage,  so  that  he  is  burned. 

The  effects  of  the  passage  of  an  electric  current  of  high  power 
through  the  human  l3ody  are  exceedingly  variable  and  uncertain.  It 
sometimes  produces  instant  death  and  again  no  result  whatever.  As 
will  be  seen  later,  nervous  shock,  more  or  less  severe  bui'us  and  a  variety 
of  minor  nervous  disorders  may  follow. 

Modifying  Conditions. — T^Tiat  is  a  current  of  high  potentiahty  and 
what  are  the  conditions  which  antagonize  its  effects  ?  The  voltage  suffi- 
cient to  j)roduce  death  is  commonty  fixed  at  1500  volts,  yet  cases  are  rcr 
ported  where  very  much  more  was  received  without  fatal  consequences, 
but  in  these  cases  it  is  probable  that  the  entire  current  did  not  enter  the 
body.  In  the  determination  of  the  strength  of  the  ciuTent  we  are  to 
consider  the  element  of  siu-face  resistance,  remembering  Ohm's  law  that 
the  intensity  varies  chiefly  with  the  electromotive  force  and  inversely 
with  the  resistance.  The  conditious  of  moistui-e  and  the  pressui'e  of 
metal  fastenings  increase  the  danger,  while  it  is  hkely  that  it  is  some- 
what diminished  by  the  di-yuess  of  the  hands  or  the  interposition  of  non- 
conducting substance. 

Gaertner  and  Edison  found  the  resistance  of  the  body  when  the  sur- 
face was  denuded  to  be  from  1600  to  2000  ohms,  but  tliis  is  probably 
much  gi-eater.  The  effects  of  the  alternatiug  and  direct  differ  greatly, 
a  voltage  of  fi-om  250  to  800  of  the  alternating  killing  a  dog  which 
withstood  a  continuous  current  of  1000  to  1400.  The  rapidity  of  the 
alternations  also  increases  the  fatality.  It  would  seem  that  sudden  iu- 
ten-uptions  have  much  to  do  with  the  serious  effects,  for  a  sudden  break 
of  the  continuous  current,  say  of  500  volts,  is  likely  to  produce  much 
more  decided  effects  than  where  no  break  is  produced. 

"  The  problem  of  the  electromotive  force  is  by  no  means  so  simple  as 
it  would  appear  fi-om  the  ordinary  statement  that  the  current  used  was 
one  of  500  or  of  2000  volts.  In  the  early  days  of  Faraday's  researches  he 
was  asked  why  a  shock  was  felt  when  a  circuit  containing  an  electromag- 
net was  broken,  and  why  no  shock  was  felt  when  the  circuit  contained 
neither  electromagnet  nor  wire  coil.  This  led  Faraday  to  study  what  he 
called  extra  cuiTents,  but  which  are  now  spoken  of  as  currents  of  self- 
induction  or  inductance.*  If  the  circuit  contains  a  coil  of  wire  it  is  found 
that  on  making  closure,  a  current  of  brief  duration  is  induced  iu  that 
wire,  which  runs  in  the  opposite  dii-ection  to  the  steady  curi-ent.  On 
openiug  the  circuit  another  cun-ent,  running  in  the  same  direction,  is  in- 
duced in  the  cu-cuit.  These  extra  ciu'rents,  or  cui-rents  of  self-induction, 
were  carefully  studied  by  Blaserna,t  who  found  that  the  extra  curi-eiit  of 
opening  was  of  shorter  iuration  but  much  more  intense  than  the  extra 
ciiiTent  of  closing,  Xow  every  d^mamo-current  necessariiy  contains  a 
coil  in  its  circuit,  and  consequently  must  present  the  phenomena  of  in- 
ductance. Hence  when  a  person  receives  a  shock  from  a  dpiamo-cur- 
rent  he  must  also  get,  when  the  cm-rent  is  broken,  a  self-induced  or  extra 
cun-ent  of  opening,  of  gi-eat  intensity  but  short  duration.  The  strength 
of  this  extra  current  depends  on  so  manj^  factors  that  it  is  not  easy  to 

*  Fleming,  Tlic  Alternate-Current  Transformer,  pp.  37  etseq.     London,  1889. 
t  Blaserna,  Giornale  di  Hcienze  Xaturali  ed  Economiche,  vol.  vi.,  p.  22,  1870. 


EFFECTS   OF  ELECTPJC   CURRENTS.  365 

calculate,  but  I  nnderstand  that  with  a  current  of  500  volts  it  may  reach 
2000  or  3000  volts. 

"  It  follows,  then,  that  where  the  factors  in  the  proljleni  are  so  variable 
we  cannot  make  any  positi\'e  assertions  and  say  that  because  A  received 
a  shock  from  a  2000-volt  current  witliout  harm  it  must  be  harmless  to 
B,  when  we  know  neither  the  body  resistance  of  A  or  B,  nor  wliat  part 
of  the  current  A  received.  As  well  say  tliat  because  A  swallows  ten 
grains  of  morphine  and  survives,  ten  grains  is  a  safe  dose  to  give  to 
B."     (Knapp.) 

Effects  of  Discharges  that  do  not  Kill. — Slight  shocks  may  result 
in  pains,  numbness,  paresis,  or  swelling  of  an  extremity ;  headache,  ver- 
tigo, insomnia,  and  disturbed  vision.  Of  course  all  such  cases  must  be 
studied  by  themselves,  for  the  temptation  to  exaggerate  some  of  the 
subjective  symptoms  is  very  great.  Persons  who  have  been  subjected  to 
shock  are  sometimes  worse  during  electrical  atmospherical  disturbances, 
their  aches  and  pains  and  nervousness  being  exaggerated  by  a  thunder- 
storm. These  symptoms  are  usually  recoveral)le,  though  there  may  l^e  a 
variety  of  residual  shock,  with  deep-seated  nervous  disturbance  of  an 
emotional  kind,  which  obstinately  persists.  Dana  is  of  the  opinion  that 
electrical  currents  when  they  do  not  kill  produce  no  permanent  harm, 
but  this,  we  believe,  is  not  always  the  case.  The  immediate  effects  of  a 
strong  non-fatal  current  (300  to  1000  volts)  are  temj^orary  tetanus,  the 
victim  falling,  with  preservation  of  consciousness,  but  a  sense  of  terror 
and  pain  which  disappears  with  the  rigidity.  Of  coui"se  the  unexpected 
plays  a  part  in  tbe  demoralization.  A  large  number  of  residual  con- 
ditions are  left  after  electric  shock.  Tliese  vary  from  nervrosism  and 
the  condition  which  is  known  as  the  traumatic  neurosis  (see  Dana's  arti- 
cle) to  light  hysteria.  The  demorahzation  that  remains  after  railway 
accidents  is  sometimes  witnessed  in  these  cases,  and  the  resemblance  to 
this  kind  of  disorder  is  very  close.  In  hypochondriacal  persons  the 
nervous  excitement  is  extreme,  and  an  excellent  case  of  Knapp's  may  be 
used  in  illustration  to  show  how  powerfully  the  imagination  may  be 
excited  when  there  is  no  actual  injmy  but  simply  fright : 

"  I  was  asked  hj  Dr.  D.  W.  Clieever  to  see  George  L.,  forty-two,  mar- 
ried, a  coachman,  who  was  said  to  l^e  suffering  from  an  electric  shock. 
I  saw  him  on  April  14,  1889,  and  ol)tained  the  foUo^riug  history  of  bis 
accident :  He  had  always  been  well  and  strong,  although  slightly  hypo- 
chondriacal ;  had  used  alcohol  pretty  regidarly,  although  never  to  excess. 
He  had  been  in  one  or  two  serious  runaway  accidents,  and  had  conducted 
himself  with  marked  coolness,  judgment,  and  courage.  Five  days  ago, 
on  the  9th,  a  wet  day,  he  was  driving  a  span  of  horses  attached  to  a 
coupe,  and  a1)out  10.30  a.m.  one  or  botli  of  the  horses  stepped  on  the 
conduit  of  tlie  West  End  Street  Eailway,  which,  from  some  defect  in  con- 
struction, h.id  beconu^  charged  with  the  electric  current  used  in  running 
the  cars,  claimed  to  lie  500  volts,  but  probably  greater.  The  horses  got 
a  shock,  dropped,  and  lay  squealing  and  struggling  for  a  moment.  As 
they  fell,  Ihe  diiver,  who  was  sitting  on  the  box  holding  the  reins,  says 
that  his  hands  felt  numb  and  queer,  and  prickled  and  tickled.  He  jumped 
down,  and  thinks  he  stepped  on  the  conduit ;  at  any  rate  he  felt  a  shock 
and  a  prickling  sensation  like  needles  in  his  legs,  which  was  worse  than 
in  his  arms,  but  neither  shock  was  painful.  He  wore  ordinary  sewed 
single-soled  shoes,  with  iron  nails  only  in  the  heels.     He  thought  he  did 


366  ^   SYSTEM  OF  LEGAL  MEDICLNE. 

not  toucli  the  conduit  with  his  hands,  but  he  may  have  touched  the  tire 
of  the  wheels,  although  he  felt  no  further  shock ;  he  cannot  say  whether 
he  knelt  on  the  conduit.  He  saw  no  sparks  before  his  eyes  and  had  no 
queer  taste  in  his  mouth.  He  sprang  to  the  coupe,  after  ahghting,  and 
got  the  horses  loose,  and  they  started  and  ran  to  the  stable.  A  friend 
who  helped  him  move  the  carriage  felt  a  slight  shock,  which  was  not 
painful.  L.  was  very  much  excited  and  felt  that  he  could  not  go  after 
the  horses.  He  did  go  to  a  house  some  two  blocks  away  to  tell  his  em- 
ployer of  the  accident.  In  doing  so  he  had  to  take  a  friend's  arm,  as  he 
had  severe  pain  in  the  knees,  especiallj^  in  the  knee-caps.  He  then  re- 
turned to  the  scene  of  the  accident,  where  he  met  the  stable-keeper,  who 
had  come  in  a  buggy  to  see  what  the  matter  was.  L.  got  into  the  buggy, 
helped  take  the  coupe  to  the  stable,  and  then  went  home.  Since  that 
time  he  has  stayed  in  the  house  most  of  the  time,  being  unable  to  do 
anything.  He  has  been  extremely  nervous  and  apprehensive,  and  for 
two  days  had  the  feeling  of  pins  and  needles  in  his  feet,  and  cramps  in 
the  calves  of  his  legs  at  night,  with  occasional  pain  in  the  knees  ;  but 
he  has  had  no  pain  in  the  knees  since  the  12th.  He  has  occasionally  an 
aching  pain  in  the  back.  He  has  a  general  shivery  feeling,  but  does  not 
feel  cold  or  sick.  He  had  a  little  headache  on  the  9th  and  the  13th,  but 
not  enough  to  amount  to  anything.  He  feels  a  little  dizzy  on  stretching. 
There  is  no  trouble  with  vision.  Sleep  has  been  very  poor  until  last 
night,  when  he  slept  pretty  well  under  thirt}^  grains  of  bromide.  He  has 
been  kept  awake  by  a  nervous  feehng,  and  when  he  did  fall  asleep  would 
start.  Night  before  last  he  shook  all  night.  To-day  he  has  a  slight  pain 
across  the  epigastrium.  He  has  had  no  sexual  desire  since  the  accident. 
Since  his  accident  he  has  had  a  constant  tremor,  most  marked  in  the 
hands  ;  this  is  rather  better  to-day.  Wlien  he  came  home  he  could  not 
put  his  toes  down  to  the  floor  very  well.  The  calves  now  feel  a  little 
stiff. 

''  L.  is  stout,  ruddy,  and  the  picture  of  vigorous  health.  He  is  very 
nervous,  apprehensive,  and  restless,  constantly  rubbing  his  hands  to- 
gether. He  fears  that  he  will  never  be  able  to  work  again  or  be  the 
man  he  was  before.  There  is  a  tremor  of  the  head  and  limbs,  most 
marked  in  the  hands;  this  tremor  is  slightly  increased  in  the  arms  on  in- 
tended movements.  The  grip  is  not  very  strong,  but  there  is  no  ataxia 
or  Romberg's  symptom,  and  he  walks  well.  The  tactile  sensibility  seems 
a  trifle  blunted  all  over  the  body,  possibly  more  on  the  left  side  of  the 
face  than  on  the  right,  but  there  is  no  distinct  line  of  division  and  no 
true  hemiansesthesia  to  touch.  The  field  of  vision,  as  tested  by  fingers,  . 
seemed  slightly  contracted  on  the  right.  All  movements  were  well  per- 
formed. There  was  slight  tenderness  over  the  calves  and  the  fourth, 
dorsal  vertebra,  and  rather  more  tenderness  over  the  upper  lumbar  ver- 
tebrae. The  knee-jerks  were  exaggerated ;  there  was  front  tap  contraction, 
and  a  tendency  to  a  patellar  clonus.  There  was  no  real  clonus  either  at 
the  patella  or  ankle,  but  a  tap  caused  several  contractions  and  a  general 
muscular  spasm.  Examination  of  chest  negative  ;  pulse  106.  No  elec- 
trical tests  were  made. 

"April  16.  Sleeping  better;  tremor  almost  gone.     Complains  of  sore- 
ness in  the  back.     Goes  out  a  little,  but  is  unable  to  do  any  work. 

"  May  30.  Getting  on  well.    Still  has  a  slight  tremor  in  the  right  hand. 
Knee-jerks  normal.    Says  he  is  not  the  same  man,  and  is  rather  despond- 


EFFECTS   OF  ELECTRIC   CUKRENTS.  307 

ent  and  anxious.  Xervousj  gets  out  of  breath  easily;  arms  give  out  on 
carrying  anything. 

"  Soon  after  he  went  with  his  employer  to  the  sea-shore,  and  resumed 
his  work." 

Jackson  reports  a  case  where  the  shock  was  severe  but  the  conse- 
quences not  fatal :  R.  R.,  aged  twenty-two,  well  developed  and  muscular, 
was  driving,  and  the  feet  of  his  horses  became  entangled  in  a  live  electric- 
light  wire.  R.,  in  his  attempts  to  remove  the  wire,  probably  took  hold 
of  some  unprotec'ted  spot  and  was  thrown  to  a  distance  of  twelve  feet 
against  a  curbstone  and  then  instantly  to  the  middle  of  the  street  again, 
swaying  l)ack  three  or  four  times.  His  hands  were  in  contact  with  tlie 
wire  about  three  minutes,  when  from  some  unknown  cause  the  current 
broke  and  he  dropped  to  the  ground  unconscious,  remaining  so  about 
ten  minutes ;  then  in  a  semi-conscious  state  was  taken  to  the  office  of  the 
writer.  Two  hours  after  was  first  seen  by  Dr.  Jackson ;  then  the  pidse  was 
100,  strong  and  bounding ;  temperature  100° ;  pupils  dilated ;  headache, 
and  was  nervous  and  irritable  ;  reflexes  increased.  The  headaclie,  accom- 
panied by  insomnia,  continued  three  days,  then  rapidly  disappeared,  and 
he  resumed  his  work  as  section-hand  without  inconvenience,  none  the 
worse  for  the  shock.  His  hands  were  blackened  from  the  finger-tips  to 
midway  between  the  ell^ow  and  wrist.  The  current  was  from  a  fifty- 
light  Thomson  &  Houston  are-machine,  ampere-cui*rent  6.8,  voltage  2100. 

Donnellan  {Medical  News,  August  4, 1894,  p.  126)  reports  a  case  where 
the  subject  received  1000  volts  and  recovered  after  remaining  comatose 
for  some  hours :  ''  On  the  20tli  of  April,  1894,  J.  R.,  aged  forty-four  years, 
while  engaged  in  repaii'ing  broken  wires  for  the  Bell  Telephone  Com- 
pany, grasped  the  ends  of  a  wire  that  had  crossed  an  electric-light  ^^-ire 
conveying  1000  volts.  He  received  the  full  force  of  the  current  through 
his  body,  and  was  immediately  rendered  unconscious.  He  was  thrown 
violently  to  the  ground,  and  could  not  be  released  until  the  cm-rent  was 
broken  by  a  fellow-lineman,  who  cut  the  wires  ajjart  with  a  hatchet. 
The  man  was  brought  to  St.  Mary's  Hospital  at  11  a.m.,  within  half  an 
hour  of  the  accident,  and  I  saw  liini  a  few  minutes  after  his  admission. 
He  was  in  pi-ofound  coma,  with  pupils  "wddely  dilated  and  irresponsive 
to  light,  breathing  stertorous,  face  pale  and  bathed  in  perspiration. 
About  ten  minutes  later  he  vomited,  and  then  became  wildly  delirious, 
so  that  it  required  the  combined  efforts  of  three  men  to  keep  him  in  bed. 
He  moaned  and  cried  incoherently,  and  tonic  and  clonic  convulsions  of 
a  severe  type  succeeded  each  other  with  gi-eat  rapidity.  At  this  time  we 
were  unal:)le  to  take  his  temperature  on  account  of  his  extreme  restless- 
ness, but  to  the  hand  it  appeared  about  normal.  His  respirations  now 
lost  their  stertorous  character  and  became  more  of  the  Cheyne-Stokes 
variety,  averaging  about  ten  per  minute  for  two  hinu'S  after  his  admis- 
sion. The  pulse  was  80  per  minute,  of  high  tension.  At  11.40  a.:m.  the 
man  was  given  morphine,  gr.  :^,  by  h^-iiodermic  injection,  and  as  the  de- 
lirium and  convulsions  did  not  abate  the  injection  was  repeated  at  12.10, 
and  soon  afterward  he  gradually  quieted  do^vn.  About  1.30  p.m.,  as 
his  respirations  were  alarmingly  feelile,  he  was  given  strychnine,  gr.  ^-^v, 
by  hypodermic  injection,  with  excellent  effect.  At  2  p.m.  he  fell  into 
an  apparently  normal  sleep,  from  which  he  awoke  four  hours  later,  con- 
scious but  slightly  dazed,  and  feeling,  as  he  expressed  it,  'tired  and  sore 
all  over.'     On  my  visit  to  the  hospital  next  morning  I  found  that  he 


368  ^   SYSTEM  OF  LEGAL  MEDICINE. 

had  slept  well  during  the  night ;  Ms  temperature  was  98.8°,  his  pulse 
72,  his  resphation  18.  He  complained  of  pain  from  a  number  of  severe 
burns  that  he  received  during  his  contact  with  the  wire.  These  burns 
were  distributed  irregularly  in  hues  over  the  back,  arms,  and  legs,  and 
evidently  were  caused  by  the  intensity  of  the  cm-rent,  as  the  clothing 
which  covered  the  affected  areas  showed  no  signs  of  having  been 
scorched.  On  questioning  the  patient  as  to  the  natm-e  of  the  accident, 
he  remembered  j)erfectly  all  of  the  incidents  of  his  morning's  work  up 
to  the  time  when  he  grasped  the  wire  that  conveyed  the  shock  through 
his  body.  After  that  moment  he  had  not  the  slightest  knowledge  of 
what  had  occurred,  and  did  not  suffer  the  least  pain  until  he  awoke  at 
6  P.M.,  as  already  stated,  to  find  himself  in  bed  in  the  hospital." 

Death  from  electricity  is,  as  a  rule,  sudden  and  accompanied  by  ap- 
pearances which  have  been  more  or  less  carefully  observed  at  the  various 
electrical  executions  that  have  occurred  in  the  State  of  New  York.  Those 
of  an  objective  character  consist  of  the  immediate  j)roduction  of  a  gen- 
eral tetanic  state  with  cm-rent-closm-e,  which  disappeared  with  current- 
opening.  There  were  also  in  some  cases  clonic  muscular  spasm  of 
the  thorax,  immediate  loss  of  consciousness,  a  slight  escape  of  mucus 
from  the  mouth,  pallor,  facial  petechiee,  dilatation  of  the  pupils,  dimness 
of  the  cornea,  and  extinction  of  the  pulse.  In  two  or  three  cases  the 
causation  of  death  was  evidently  not  immediate — notably  in  that  of 
Kemmler.  One  of  the  condemned — the  most  horrible  case  of  all — was 
fli'st  actually  anaesthetized  after  being  removed  from  the  "  electrical  chair," 
and  when  rendered  insensible  was  finally  put  to  death  by  a  second  turn- 
ing on  of  the  current. 

WiUiam  G.  Taylor  (Brown,  J.  W.,  "  The  Latest  Electrocution,"  Medical 
Record,  New  York^  1893,  vol.  xliv.,  p.  222)  was  electrocuted  at  Auburn,  July 
27,  1893.  A  current  of  1260  voltage  was  tm-ned  on  at  a  given  signal, 
and  with  a  crash  the  legs  shot  forward  and  upward,  tearing  the  standard 
and  entire  front  from  the  chair.  For  exactly  52  seconds  this  condition 
was  sustained  and  then  the  current  was  shut  off.  The  condemned  now 
pitched  forward  and  would  have  fallen  upon  his  face  had  he  not  been 
restrained  by  straps.  For  20  seconds  he  remained  apparently  dead,  a 
slight  froth  oozing  from  the  mouth  below  the  mask ;  then  gasped.  An 
attemi^t  was  made  to  again  turn  on  the  current,  but  this  failed.  Pulse 
could  not  be  felt.  Thirty  seconds  later  pulse  was  slight  and  thready, 
respiration  6  per  minute.  He  was  unbound  and  placed  on  a  cot  and 
removed  to  adjoining  room  ;  respiration  now  12  to  13,  pulse  100  and  fuU, 
breathing  stertorous,  and  features  possessing  the  idiotic  expression  seen 
in  apojjlectic  seizures.  Breathing  continued  labored,  but  increasing  in 
frequency,  and  at  half  an  hour  after  contact  was  18  and  pulse  120  and 
full.  He  now  made  the  first  movement  of  left  foot  and  in  a  very  few 
moments  became  restless,  moving  legs  and  arms  and  rolling  from  side 
to  side.  He  was  now  given,  hypodermically,  %  gr.  morphia.  After  35 
minutes,  no  appreciable  effect  being  produced,  a  cone  was  saturated  with 
^  chloroform  and  f  ether  and  appHed.  He  opened  his  eyes  and  tried 
to  object  to  this.  Forty-eight  minutes  after  contact  pulse  was  130,  full 
and  vigorous.  Readily  responded  to  the  anaesthetic  and  was  again  placed 
in  the  chair  and  a  second  contact  made  and  continued  40  seconds ;  an 
examination  proved  him  dead  from  a  voltage  of  1220.  Autopsy  1  hour 
and  34  minutes  later :  no  rigor  mortis,  slight  eschar  on  temple,  exten- 


EFFECTS   OF  ELECTRIC   CVRItEXTS.  3G9 

sive  one  on  right  leg,  slight  congestion  of  peritonenm,  Inngs  slightly 
congested  at  apex,  one  ounce  sei-um  in  pericanliniii,  ollici-wise  normal 
condilions,  blood  fluid  throughout. 

This  case  and  another  (piite  recently  reported  in  France  by  Arsouval 
raise  a  grave  question  of  how  electricity  kills,  and  whether  the  production 
of  aspliyxia  is  not  what  really  takes  i»lace.  The  subject  of  the  French 
case  was  a  workman  who  received  5000  volts  (!)  in  some  way,  and  was  re- 
stored to  life  by  artifi(!ial  respiration  and  other  means.  Again  and  again 
cases  "struck"  by  lightuing  have,  though  apparently  some  time  dead, 
been  resus(jitated,  and  it  certainly  is  a  grave  (pu^stiitn  whether  po.st- 
niortem  examinations  shoidd  not  always  be  delayed  until  tlie  matter  of 
■deatli  is  indisputably  settled. 

Buchanan  (London  Lancet,  1892,  vol.  i.,  p.  G29)  reports  a  fatal  case  of 
a  man  who  received  a  current  of  2400  volts.  He  was  seen  ten  minutes 
after  the  accident.  His  face  w'as  H\dd,  lips  congested,  pupils  dilated, 
bloody  mucus  oozed  from  the  nares,  hands  alnn)st  clenched;  he  was 
lying  on  his  back  inclined  to  the  right  side.  Artificial  respiration  was 
resorted  to ;  he  respired  three  times,  and  then  died  in  four  minutes,  quite 
rigid.  Tliere  were  no  marks  on  the  head  or  body,  but  a  dirty  spot  on 
the  right  hand,  which  was  probably  the  japan  from  an  iron  liar  held  in 
the  hand,  he  having  struck  at  the  induction-^m-e  while  the  insulating 
india-rubber  was  fusing.  After  having  struck  at  the  wu-e  he  fell  back 
with  a  cry  for  help  and  was  then  carried  aAvay  insensible.  Post-mortem 
31  hours  after  deatli :  rigidity  conspicuous ;  no  signs  of  violence ;  lividity 
marked ;  superficial  intestines  shghtly  congested ;  deeper  abdominal  con- 
tents highly  congested  (hypostatic) ;  urinary  bladder  congested  :  spleen 
enlarged  and  deeply  congested,  and  adherent  to  posterior  parts  by  bauds 
of  adhesions ;  stomach  evidenced  old  inflammation ;  heart  normal ;  su- 
perficial veins  congested ;  right  auricle  distended ;  right  ventricle  flaccid ; 
left  ventricle  firm  and  solid ;  left  auricle  containing  from  one  to  two 
ounces  of  liquid  blood ;  right  lung  firmly  and  universally  adherent ;  both 
lungs  congested,  right  more  than  left,  tarry  blood  and  air  exuded  on 
pressure,  floated  in  water,  and  absence  of  disease  ;  epiglottis,  larynx,  and 
trachea  deeply  congested,  othermse  normal ;  brain  and  spinal  cord  con- 
gested, otherwise  normal ;  death  evidently  by  asphyxia. 

One  of  the  carefully  detailed  autopsies  (that  of  Jugigo)  made  by  Van 
Oiesen  mav  be  presented  {The  Lifficfion  of  the  Death  rciiatti/  hi/  .]re((ns 
of  EJevtt'ic'ity,  by  C.  F.  Macdonald,  M.D.,  New  York,  1892,  D.  Appleton  & 
Co.),  and  fully  describes  the  appearances  found  in  other  cases:  "The 
post-mortem  examination  was  held  four  hours  after  death.  The  pupils 
were  alike  and  moderately  contracted.  The  body  was  well  nourished  and 
unusually  well  developed.  The  anterior  epithelial  cells  of  the  cornea  had 
desquanuited  from  the  central  portion  by  the  action  of  heat.  There  was 
a  l)ulging  forward  of  the  sclera  of  the  left  eye  at  the  left  sclem-corneal 
junction.  Conjunctiva  anamiic.  The  scalp  and  the  skin  covering  the 
neck  had  a  dull,  purphsh  hue.  The  skin  of  the  anterior  surface  of  the 
bod}^  was  not  discolored  or  ecchymosed.  At  the  flexure  of  both  elbows 
w^ere  a  number  of  s;sTnmetrical  linear  ecclnTuoses,  which  were  more 
marked  on  the  right  side ;  also  a  curved,  narrow  ecchymotic  hue  just 
below  the  outside  of  the  right  nipple.  These  probably  were  caused  by 
the  straps.  At  the  posterior  surface  of  the  right  knee-joint,  and  on  the 
posterior  and  inner  and  upper  sm-face  of  the  calf,  the  epidermis  was 


370  ^   SYSTEM  OF  LEGAL  MEDLCIXE. 

raised,  Tvi'inkled,  and  folded.  At  the  flexiu'e  of  tlie  knee- joint  the  epider- 
mis had  been  torn  away  to  the  extent  of  ahout  an  inch  in  diameter.  The 
right  lower  extremit\^  was  flexed  and  bent  more  to  the  median  Hne  than 
its  fellow.  There  was  a  sHght  discharge  of  thin,  milky  fluid  from  the 
ni-ethra  and  some  still  remaining  in  the  canal.  A  sample  of  this  fluid  was 
taken  for  microscopical  examination.  Post-mortem  rigidity  well  marked, 
except  in  the  arms,  where  it  was  only  slight.  The  whole  j)osterior  sur- 
face of  neck,  tmnk,  arms,  and  lower  extremities  Avas  of  a  dull,  pur]3hsh 
hue.  There  were  a  few  shght  bhsters  on  both  temples  and  both  cheeks 
and  eyeUds.  There  were  raised  wMtish  streaks  on  both  sides  of  the  neck, 
just  below  the  angle  of  the  jaw.  The  trunk  was  opened  by  a  straight 
incision  from  the  to]3  of  the  sternum  to  the  pubes.  The  fat  was  an  inch 
thick  over  the  abdomeu.  Muscles  red  and  fii-m.  Diaphi'agm  at  left  side 
was  found  at  the  level  of  the  sixth  intercostal  space,  and  on  the  right 
side  at  the  fifth  intercostal  space.  Portions  of  small  intestines  were 
taken  for  microscopical  examination.  Examination  of  heart :  auricles 
and  ventricles  flaccid  and  in  diastole  and  filled  with  fluid  blood.  The 
larger  vessels  were  tied  and  the  heart  removed.  The  left  ventricle  was 
well  filled  with  fluid  blood  but  no  elots.  The  auricles  were  the  same. 
The  blood  was  of  the  same  color  in  the  left  ventricle  as  in  the  right. 
Valves  noriaal.  On  opening  the  vessels  a  large  quantity  of  dark-colored 
licpiid  blood  escaped,  half  filling  the  pleural  cavity.  There  were  no 
pleiu'al  adhesions.  Lungs  perfectly  healthy,  but  slightly  congested. 
The  spleen  was  found  to  be  of  normal  size,  the  capsule  smooth,  j^ulp 
fii'in  and  uniformly  filled  with  blood,  and  the  arrangement  of  the  Mal- 
pighian  bodies  and  splenic  connective  tissue  entirely  normal.  The  pan- 
creas was  j)erfectly  normal  and  a  portion  removed  for  microscopical  ex- 
amination. Liver  entirely  normal,  and  a  portion  was  also  removed  for 
microscopical  examination.  The  gall-bladder  was  filled  -with  bile.  Left 
kidney :  the  capsule  was  non-adherent.  It  was  rather  large  and  the  cor- 
tex of  normal  thickness.  The  kidney  was  uniforml}^  injected,  and  the 
markings  in  the  cortex  were  normal  as  to  number  and  arrangement.  The 
right  kidney  was  in  the  same  condition.  The  stomach  was  empty,  the 
mucous  membrane  pale ;  the  rug«  were  well  marked  and  perfectly 
healthy.  The  intestines  were  healthj^  The  small  intestines  were  filled 
with  semi-fluid  ffeces.  The  large  intestines  showed  the  same  condition. 
The  minary  bladder  was  normal  and  half  full.  Examination  of  brain  : 
The  brain  was  exposed  by  a  straight  incision  of  scalp  over  the  vertex 
fi'om  ear  to  ear,  and  saw  cuts  through  the  skull  at  a  slight  angle  and 
at  the  level  of  the  ej^ebrows.  The  scalp  showed  several  old  scars,  and 
was  slightty  less  adherent  under  those  portions  where  the  electrode  was 
attached.  The  skull  was  s^anmetrical.  The  dura  mater  was  normal 
and  the  vessels  moderately  dilated.  The  longitudinal  sinus  was  found 
to  be  nomial  and  contained  some  fluid  blood.  The  brain  was  removed 
in  the  usual  way.  The  pia  mater  was  uniformly  thin  and  transparent ; 
the  vessels  in  a  medium  state  of  congestion ;  subpial  fluid  small  in 
amount.  The  blood  was  eveiywhere  fluid  in  the  meshes  of  the  pia 
mater.  There  was  no  apparent  difference  in  that  portion  which  the  elec- 
trode covered.  The  vessels  at  the  base  were  perfectly  normal.  The  ven- 
tricles contained  a  small  amount  of  clear  fluid.  The  roof  and  floor  of  the 
lateral  ventricles  were  normal.  The  ependyma  was  smooth  and  trans- 
parent.    White  substance  fii-m.     Gray  matter  normal  in  every  respect. 


EFFECTS   OF  FLECTIUC   VUUIIEXTS.  ;j71 

Floor  of  the  fourth  ventricle  at  the  npj)cr  half  contained  some  dilalcd 
vessels,  and  on  the  left  side  there  were  a  nunil)er  of  minute,  radiatin<; 
petechial  spots  from  one  to  two  millimeters  in  diameter.  The  spinal 
cord  was  exi)osed  in  the  usual  maimer.  The  extei-nal  appearance  of 
both  cord  and  membranes  was  entirely  normal,  and  the  vessels  contained 
if  anything-,  even  less  l)lood  than  usual,  due,  probabl}',  to  the  short  time 
that  had  elapsed  between  the  occurrence  of  death  and  the  holding-  of 
the  autopsy.  Sections  half  an  inch  apart  showed  Jiothing  abnormal.  A 
portion  of  both  sciatic  nerves  was  taken  for  microscopical  examination. 
Owing  to  the  great  length  of  time  necessary  to  make  this  autopsy  as 
comi)letely  and  minutely  as  was  done,  and  the  sul>sequent  careful 
microsco])ical  examinations,  it  was  not  considered  necessary  to  examine 
the  brain  and  spinal  cord  in  the  other  cases,  esj^ecially  as  nothing  of  any 
importance  had  been  observed  in  these  organs  in  this  case.  The  micro- 
scopical examinations  showed  no  recognizal)le  changes  in  the  tissues  or 
organs  of  the  1)ody.' 

"  Falls  and  Other  Injuries. — As  a  result  of  falls  which  follow  the  receipt 
of  a  shock  l)y  the  victim,  who  nuiy  be  engaged  in  a  high  place  in  repair- 
ing wii-es  or  doing-  some  other  work,  there  may  of  course  be  almost  any 
kind  of  other  injury,  wljich  varies  from  simple  concussion  to  fracture  of 
the  skull  or  spine ;  but  these  do  not  concern  us  except  so  far  as  they 
are  the  result  of  an  initial  shock,  the  mode  of  receipt  of  which  is  to  be 
determined,  as  well  as  whether  the  contact  was  due  to  the  victim's  care- 
lessness, or  whether  he  was  unnecessarily  subjected  to  danger  through 
the  fault  of  others.  In  New  Yoi-k  City  and  elsewhere  there  are  any 
number  of  "dead"  wires,  which  become,  by  crossing,  the  conveyers  of 
fatal  currents,  and  these  are  often  responsible  for  such  accidents. 

Electric  Burning. — Cases  of  another  kind  are  those  in  which  the 
electric  current  produces  1)urns  of  greater  or  less  gravit}'.  Xaukevell 
reports  the  case  of  an  electric-light  trimmer  who  I'eceived  accidentally 
the  full  pressure  of  2400  volts  through  his  left  hand,  which  held  the 
wire.  He  was  rendered  insensible ;  his  legs  were  drawTi  up  to  the 
trunk.  This  brought  his  fidl  weight  on  the  wire,  which  then  broke 
and  released  him.  He  was  taken  to  the  hospital  and  there  recovered  con- 
sciousness, and,  though  excited,  gave  an  account  of  the  accident.  The 
thumb  and  forefinger  were  black  and  charred,  and  an  eschar  was  perceived 
which  extended  on  the  dorsum  of  the  hand  to  the  end  of  the  idna,  the 
traict  being  burned  to  .the  l.)one.  The  burned  parts  were  insensil)le,  but 
there  was  intense  pain  in  parts  not  burned.  On  removal  to  bed  four  toes 
of  the  left  foot  wei'e  found  burned  on  the  palmar  surface,  each  eschar 
being  about  the  size  of  a  threepenny  piece.  There  was  no  mark  on  the 
boot.     He  recovered  in  the  course  of  a  few  weeks. 

The  following  fatal  case  of  burning,  which  was  carefully  ol)served 
by  Dr.  Galvin  at  the  Boston  City  Hospital,  is  cited : 

"Electric  shock.  Fall  from  pole.  Severe  burns  from  electric-light 
wire.     Sloughing  of  burns,  gi-adual  failure,  and  death. 

"  Peter  K.,  nineteen,  single,  born  in  Ireland,  a  linenum.  Some  alcohol ; 
denies  syphilis.  At  2  p.m.  on  Novend)er  17,  1886,  while  on  a.  pole  trim- 
ining  an  electric  light,  was  severely  l)urned,  arul  fell  about  twenty  feet. 
Has  no  recollection  of  the  fall,  or  how  he  struck.  Considerable  shock. 
Well  developed  and  nourished.  Kight  wrist  burned  su])erficially  over  a 
space  about  three  inches  each  wav.  Eight  thenar  eminence  burned  through 


372  ^   SYSTEM  OF  LEGAL  MEDTCLXE. 

to  the  muscles,  and  adductor  pollicis  laid  bare  over  a  space  the  size  of  a 
quarter  of  a  doUar.  Middle  fiiiger  bm-iied  to  the  bone  over  a  space  about 
two  inches  long,  beginning  at  tip  of  finger,  and  on  the  back  of  it.  Third 
finger  burned  over  a  space  about  one  inch  long  on  the  back.  Little  finger 
bui-ned  the  same  as  the  thii-d.  Two  middle  toes  on  right  foot  bui-ned  a 
little.  Poidtices  to  burns.  Two  wounds  of  forehead  over  right  eye.  each 
about  thi-ee  quarters  of  an  inch  long,  and  one  of  them  just  over  the  border 
of  the  orlut.  Large  subconjunctival  hemoiThage  in  left  eye.  Both  wounds 
stitched  with  catgut,  and  sealed  up  with  absorbent  cotton  and  compound 
tinctui-e  of  benzoin,  after  being  powdered  with  iodoform.  Brandy,  ■'.  xxv, 
and  Magendie's  solution,  "^'L  v.  subcutaneously ;  heaters.  Xovemlier  19th. 
On  dangerous  hst.  Poultice  has  made  burns  much  less  paiufid.  Little 
finger  of  left  hand,  which  had  a  brass  ring  on  it,  was  slightly  burned 
underneath  the  ring.  November  22d.  Little  finger  of  left  hand  has 
turned  completely  black.  Sloughs  on  right  hand  are  deeper,  and  are  sep- 
arating out.  Ai-m  swelled  to  elbow.  To-night  he  feels  miserably,  and 
says  he  felt  a  repetition  of  the  shock  of  the  electricity  at  four  o'clock  this 
afternoon,  the  time  of  the  accident,  or  very  near  it.  Still  on  the  danger- 
ous hst.  November  25th.  Has  been  delu-ious  for  some  days.  Pulse  and 
temi)erature  up.  Very  sick  to-day,  and  failing  fast.  This  afternoon  was 
constantly  muttering  to  himself.  Pulse  getting  weaker  and  weaker. 
Takes  brandy,  a  teaspoonful  at  a  time.  Sloughs  on  right  hand  very 
deep  and  foul-smelling.  Little  finger  of  left,  hand  entirely  dead.  Died 
at  4.45  P.M." 

The  Ijiuns  are  chiefly  about  the  hands,  and  depend  in  severity  ^"ery 
much  upon  the  di-yness  of  the  skin :  a  moist  skin  conducting  more  freely, 
though  there  are  cases  where  the  ciu'rent  is  so  sti'ong  and  the  contact  so 
perfect  imder  aU  conditions  that  the  ine^'itable  result  is  a  liad  Imrn  or 
series  of  burns.  These  are  deep  and  do  not  heal  quickly,  are  attended 
by  sloughing,  but  not  necessarily  by  much  surgical  shock.  Many  of 
the  burns  are  severe  as  the  victim  is  unable  to  let  go  or  because  he  is 
entangled  with  wn-es  so  that  the  contact  is  prolonged.  Sometimes  an- 
SB.sthesia  and  paralysis  of  the  forearm  or  arm  follows  the  receipt  of 
such  a  shock. 

Medical  Electricitj'. — ^Accidents  in  connection  ^ith  the  medical  use 
of  electi-icity  are  rare,  and  arise  from  the  incautious  application  of  cur- 
rents of  high  tension  to  the  head,  especially  wheu  the  subject  is  a  person 
of  advanced  age,  and  wheu  there  is  latent  cerebral  disease.  The  too 
early  use  of  electiical  cuiTents  after  cerebral  hemorrhage,  or  when  in- 
flammation of  the  nervous  stiiictures  is  concerned,  is  prone  to  retard  the 
cure  or  precipitate  fi'esh  trouble.  In  certain  peripheral  parah'ses  ex- 
cessive electrical  stimulation  may  do  much  harm,  but  in  such  cases  what 
the  electiical  reactions  were  before  treatment  must  be  determined,  and 
the  nature  of  the  jjarticular  disease  settled.  Vertigo  and  transitory 
losses  of  consciousness  have  been,  obseiwed  by  the  wi-iters  as  sequell^e 
of  cereljral  distiu'bance  due  to  galvanic  currents  of  high  potentiality. 
Static  electiicity  may,  through  a  careless  use  of  Le^'den  jars  and  con- 
nections, produce  a  shock  of  considerable  violence ;  and  a  case  is  known 
to  one  of  us  where  the  transmission  of  a  six-inch  spark  through  the 
head  produced  a  temporaiy  unconsciousness,  and  gi-eat  subsequent 
weakness.  Induced  ciuTents  from  ordinaiy  medical  apparatus  are  not 
dangerous. 


EFFECTS   OF  ELECTRIC  CURRENTS.  373 

Late  Legal  Decisions — Some  recent  medico-legal  cases  are  cited 
in  illustration  of  the  issues  that  may  arise.  ■  An  interesting  case  is  that 
of  the  !S<)utluvest('rn  Telegraph  and  Telq^hoiie  Coiiipan/j  vs.  Eobinson,  2  U.  8. 
App.  205,  in  which  it  was  decided  that  though  the  injury  was  inflicted  in 
a  manner  that  the  telephone  company  coukl  not  prevent,  they  were  liahle. 
On  the  aft(^rnoon  of  October  29,  1889,  J.  B.  Rol^inson  was  traveling-  on 
horsebac'k  on  the  Dallas  and  McKinney  Highway,  Texas,  during  a  heavy 
tliund(ir-storm,  and  came  in  contact  wdth  one  of  the  telephone  company's 
wires,  whicli  had  fallen  and  was  suspended  within  a  few  feet  from  the 
ground,  and,  the  wire  being  heavily  charged,  he  was  knocked  from  his 
horse  and  serionsty  injured.  The  jury  returned  a  verdict  for  $2500, 
which  the  United  States  Circuit  Com-t  of  Appeals  for  the  Fifth  Cii'cuit 
affirmed.  The  telephone  company  claimed  that  the  electricit}'^  by  which 
the  injury  was  caused  was  produced  by  the  liea^y  thunder-storm  w^hich 
was  raging  at  the  tune.  In  answer  to  this  the  court  said:  "If  the 
electric  fluid  with  which  the  ware  of  the  telephone  company  was  charged 
at  the  time  was  an  element,  or  the  main  element,  in  the  production  of  the 
injuries  to  the  defendant  in  error,  still  it  is  clear  that  the  displaced  wire 
furnished  the  means  of  the  communication  of  the  dangerous  force  w^hich 
resulted  in  the  injury  to  him." 

An  ordinary  and  clear  case  of  negligence  is  the  case  of  Clements  vs. 
Lonisiann  Mectric  Lif/ltf  Co.,  44  La.  Ann.  692.  Joseph  Clements,  who  was 
a  tinsmith,  was  killed  on  October  4, 1890,  by  a  current  from  the  wires  of 
the  Louisiana  Electric  Light  Company,  while  repairing  the  roof  of  a  gal- 
lery in  New  Orleans.  The  wires  were  fastened  to  a  "house"  on  the  gal- 
lery. They  were  insulated  and  appeared  to  be  safe.  While  cleaning  the 
gutter  of  the  roof  he  came  in  contact  with  two  wires  and  w^as  immedi- 
ately killed.  After  the  accident  the  insulation  on  the  "s\di'es  W' as  discovered 
to  be  much  worn  by  exposure.  This  action  was  brought  by  the  parents 
of  Clements  for  damages,  and  the  jury  awarded  them  $5000.  The  Su- 
preme Court  of  Louisiana  affirmed  the  judgment,  holding  that  the  de- 
fendants were  neghgent  in  not  properly  insulatiug  the  wii"es,  but  regarded 
the  verdict  as  excessive,  and  reduced  it  to  $2000. 

An  important  case  is  that  of  Burt  vs.  Douglas  Connty  Street-Baihcai/, 
83  Wis.  229,  where  suit  was  brought  by  Burt,  who  received  a  shock  in 
the  manner  below  stated.  The  defense  was  contributory  neghgence, 
which,  however,  was  not  entertained.  The  defeudants  operate  a  street- 
railway  in  Superior  City,  Wis.  On  December  23,  1890,  they  ran  two 
cars  attached  together.  Each  car  was  built  with  a  platform  at  each  end, 
guarded  by  a  dash-board,  with  an  iron  handle  attached.  The  plaintiit' 
got  upon  the  first  of  these  cars,  but,  finding  it  cold,  attempted  to  go  to 
the  other,  where  there  Avas  a  fire,  w'hile  the  cars  were  mo^dng,  and  took 
hold  of  the  iron  handle  on  each  car  to  step  from  one  car  to  the  other. 
The  wires  attached  to  the  cars  were  not  properl}-  insulated,  and  the  elec- 
tricity escaped,  the  handles  becoming  heavily  charged  with  it,  unknown 
to  plaintiff,  and  when  he  took  hold  of  them  he  received  a  severe  shock 
and  was  badly  injm^ed,  being  dragged  a  considerable  distance  by  the  ears, 
because  he  was  unable  to  loosen  Ids  hold  of  the  handles.  He  brought 
suit  against  the  railway  company  for  damages  and  received  a  verdict  f or 
$1500,  which  the  Supreme  Court  of  Wisconsin  affirmed,  holding  that  the 
-company  was  chargeable  with  notice  of  the  defective  condition  of  theii-  ap- 


374  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

paratus,  and  tliat  it  was  not  negligence  for  the  plaintiff  to  pass  fi'om  one 
car  to  the  other  while  in  motion. 

In  the  case  of  the  Colorado  EJedric  Co.  vs.  Luliders,  11  Colo.  505,  the 
action  was  defeated  on  the  score  that  the  person  was  injm-ed  at  a  time 
when  he  should  not  have  been  working  at  the  wii-es  and  had  been  so 
forbidden  to  do ;  but  a  verdict  for  the  defendant  was  reversed  on  eiTor. 
Charles  Lubbers  was  employed  by  the  Colorado  Electric  Company  as 
a  carpenter  to  assist  in  taking  care  of  its  light-towers.  At  3.30  o'clock 
in  the  afternoon  of  December  17, 1881,  he  was  sent  by  the  superintendent 
to  remove  a  lamp  and  connect  the  wires  with  the  cu'cuit.  The  usual  time 
for  tui-ning  on  the  cui'rent  at  that  time  was  from  4.30  to  4.45  o'clock. 
This  was  outside  of  his  duties  and  he  was  not  experienced  in  the  work. 
While  connecting  the  wii-es  after  remo^dng  the  lamp  the  current  was 
turned  on  and  he  was  shocked  and  thi'own  to  the  ground  and  seriously 
injui-ed.  Lubbers  sued  the  company  for  damages  and  received  a  ver- 
dict. On  appeal  the  Supreme  Court  of  Colorado  held  that  the  question 
of  contributory  negligence,  which  was  the  onl}^  defense  urged,  was  a 
matter  of  fact  for  the  jiuy.  But  the  Trial  Court  admitted,  under  objec- 
tion, evidence  that  after  the  accident  the  company  put  up  notices  in  its 
works  warning  all  employees  to  quit  work  at  four  o'clock  and  not  to  con- 
tinue mthout  notifying  the  officers.  The  coui't  held  that  this  was  error, 
and  on  this  ground  reversed  the  judgment. 

A  case  resembhng  the  last,  in  the  question  of  the  element  of  time,  was 
that  of  Kraafz  vs.  Brush  Electric  Light  Co.,  82  Mich.  457.  This  was  an 
action  for  damages  caused  by  negligence  brought  by  Almeron  Ki-aatz 
against  the  Brush  Electric  Light  Company,  by  whom  he  was  emploj^ed 
as  a  trimmer.  On  August  19,  1886,  at  nhie  o'clock  in  the  morning,  he 
was  trimming  lamps  on  an  electric  tower  in  Detroit,  when  he  received  a 
shock  and  was  seriously  injured  by  the  contact  of  a  day-'O'ii'e  wliich  was 
in  operation  with  the  wire  upon  which  he  was  working,  which  was  "  dead  " 
at  the  time.  There  was  a  verdict  for  the  plaintiif ,  which  was  affirmed  by 
the  Supreme  Com-t,  reciting  the  above  facts.  One  of  the  gi'ounds  of 
defense  was  that  the  injm-ies  had  been  caused  by  a  stroke  of  jDaralysis, 
but  tills  being  a  matter  for  the  jury  the  coiu't  refused  to  go  into  it,  the 
jury  ha\'iug  decided  the  question. 

The  defense  of  trespassing  was  made  in  the  case  of  Sullivan  vs.  Boston 
&  A.  R.  R.  Co.,  156  Mass.  378.  Daniel  SuUivan  and  another  boy  were 
playing  ball  near  a  coal-shed  of  the  defendant,  on  Lehigh  Street,  Boston. 
The  baU  was  batted  and  fell  on  the  coal-shed,  and  Sullivan  went  uj)  and 
recovered  the  ball.  He  then  came  into  contact  with  two  naked  copper 
wii'es  on  the  roof,  which  were  used  by  the  defendant  to  conduct  electricity, 
and  received  injuries  resulting  in  his  death.  Charles  Sullivan,  as  ad- 
ministrator, then  brought  tliis  action  against  the  railroad  company  for 
damages  for  his  death,  and  on  the  trial  the  court  ordered  judgment  for 
the  defendant.  The  Supreme  Judicial  Court  of  Massachusetts,  on  appeal, 
affirmed  the  judgment  on  the  gTOund  that  the  wire  was  a  lawful  apj^a- 
ratus,  and  not  a  trap,  and  that  decedent,  if  not  a  trespasser,  was  only  a 
licensee,  and  that  therefore  the  company  was  not  liable. 

A  case  in  which  the  injured  man  was  hurt  by  the  \nves  of  another 
company,  which  approximated  those  he  was  repairing,  is  that  of  the  Au- 
gusta Raihvay  Co.  vs.  Andrews,  89  Ga.  653,  in  which  the  defense  of  tres- 


EFFECTS   OF  ELECTIilC    CURIiENT,'^.  375 

passing'  was  advanced.  Andrews  was  employed  by  a  telephone  company 
in  Aug'usta,  Ga.,  to  put  uj)  wires.  On  the  same  poles  on  wliich  these 
were  to  be  jilaeed  were  wires  of  tlie  Aiif2:usta  Fii-e  Department  and  tlie 
Augusta  Railway  Company.  While  attemjjting  to  place  tlie  teleijlione- 
wire  over  the  lire-alanu  wii-e  he  received  a  shock  which  threw  him  to  the 
ground  and  seriously  injured  liijii.  He  brought  suit  against  the  railway 
comj>any  for  damages,  charging  negligence  in  the  opei-ation  of  their  "feed- 
wire"  in  allowing  it  to  come  into  contact  with  the  fire-alarm  wire  at  tlie 
intersection  of  two  streets,  and  that  the  contact  of  the  two  wires  produced 
the  current  which  caused  his  injuries.  The  verdict  was  for  the  plaintiff, 
but  on  a|)peal  the  Supreme  Court  of  Georgia  reversed  the  judgment, 
holding  that  the  railroad  company  was  under  no  duty  to  protect  him,  that 
lie  had  not  l)eeii  granted  x>ei'itiissioii  to  climb  the  poles  and  thus  became 
.a  trespasser,  and  that  therefore  he  could  not  recover. 

Ill  the  case  of  Piedmont  EUetylc  IUumu\(dlu<j  Co.  vs.  Patteson^s  Administ. 
the  issue  depended  upon  defective  apparatus  provided  by  the  defendant. 
Miles  Patteson,  a  negro,  about  thirty  years  of  age,  uneducated,  but 
noted  as  a  cautious  man,  had  been  in  the  employ  of  the  illuminating 
■company  as  a  day-trimmer  of  street  electric  lights  in  Lynchburg  for  about 
four  months  at  intervals.  About  eight  o'clock  on  the  night  of  March  23, 
188G,  it  was  discovered  that  one  of  the  circuits  was  open,  and  Patteson 
and  several  others  were  sent  out  to  repair  the  trouble,  each  taking  with 
him  a  "  shnnt "  cord  or  switch.  The  shunt  cord  which  Patteson  took  was 
visibly  defective  and  absolutely  worthless.  Soon  after  they  started  to 
work  the  broken  line  lit  up  with  a  flash,  and  Patteson  was  discovered 
hanging  at  the  top  of  a  lamp-pole  dead.  He  had  found  the  break,  and  in 
trying  to  turn  on  the  current  grasped  the  shunt  cord  at  its  defective  end 
with  one  hand  and  put  his  other  on  a  live  wire.  His  two  hands  were 
severely  burned  and  the  insulation  of  his  shunt  cord  was  burned  off  at 
both  ends,  one  end  being  entirel}^  broken  off,  showing  that  his  death  was 
■caused  by  the  current  passing  through  his  body  by  reason  of  the  defective 
shunt  cord  while  fixing  the  lamp.  The  company  proved  that  Patteson 
had  received  erroneous  instructions  from  another  negro,  under  whom  he 
had  been  placed  when  he  entered  their  employ,  as  to  the  disadvantage 
•of  the  shunt  cord ;  also  that  the  circuit  could  have  been  tested  without 
turning  on  the  ciuTcnt.  Patteson's  widow,  as  administratrix,  brought 
suit  against  the  company  for  damages  for  liis  death,  and  the  jury  ren- 
dered a  verdict  for  $3000,  which,  on  api^eal,  the  Supreme  Court  of 
Appeals  of  Virginia  reversed,  saying :  "  The  plaintiff's  own  testimony 
fails  to  prove  negligence  on  the  part  of  the  defendant  company  unmixed 
by  the  concurring  cooperating  negligence  of  the  decedent,  but  for  which 
the  accident  could  not  have  occurred." 

A  negligence  case  where  damages  were  obtained  for  the  loss  of  a 
horse  is  that  of  the  Electric  Baihvmj  Co.  vs.  SJielton,  89  Tenn.  423.  This 
was  an  action  by  C.  F.  Slielton  against  the  Union  Electric  Railway 
Ooinpany  and  the  Cumbeiiand  Telephone  and  Telegraph  Comi)any  for 
damfiges.  During  a  fire  the  wall  of  the  burning  building  fell  and  broke 
a  pole  of  the  telegraph  company,  which  in  falling  l)roke  the  wii-es  at 
several  points ;  one  of  these  wires  fell  across  the  trolley- wire  of  the  rail- 
Avay  company,  and  while  resting  on  it  Shelt^on's  horse  came  in  contact 
with  it  and  was  killed.     The  trolley-wire  was  not  guarded.     The  Cu-cuit 


376 


A   SYSTEM  OF  LEGAL  MEDICIXE. 


Court  gave  judgment  for  plaintiff,  -whicli  was  afSi-med  by  the  Supreme 
Coui't  of  Tennessee,  who  held  that  both  companies  were  negligent  in 
not  properly  protecting  theu'  wu*es  from  contact  in  case  the  telephone- 
Avire  fell. 


BIBLIOGEAPHY. 


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(15) 

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1887. 

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1888. 

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1889. 

(19) 

1889. 

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1889. 

(21) 

1889. 

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1889. 

(24) 

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90.  ( 

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92.  ( 

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(38) 

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liidiardson,  "Med.  Times  and  Gazette,"  May  15th,  Jiuie  5th,  August  14th.- 

Charcot,  "Legons  du  Mardi,"  vol.  xi.,  No.  19. 

CJoives,  "Loudon  Lancet."  vol.  ii. 

Gart)ier,  "Medizinisehe  Jahrbiicher,"  p.  519. 

Jolh/,    "  Untersuchvmgen  liber  den  elektrischen  Leituugswiderstand  des- 

mens.  Korp."     Strassburg. 
Grange,  "Aunales  d'Hygiene,"  etc.,  January  and  April. 
Sheild  and  Delepine,  "British  Medical  Jom-nal,"  March  14th. 
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DArsonval,  "  Comptes  Eendus."  etc.,  8th  series,  tome  iv.,  p.  95. 
Terry,  "No.  Am.  Jour,  of  Homeopathy."  December. 

Brown,  "  The  Comparative  Danger  to  Life  of  the  Alternating  and  Con- 
tinuous Ciu'reuts." 
"Occidental  Med.  Times,"  October,  p.  562. 
Petersen,  "New  York  Med.  Eecord,"  November  2d. 
Brown,  "  North  American  Eeview."  November. 

Petersen,  "  Report  of  Committee  of  New  York  Medico-Legal  Society." 
Edison,  "North  American  Eeview."  November. 
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"Boston  Medical  and  Surgical  Journal,"  vol.  cxxv.,  p.  270. 
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Surgical  Joiu-nal,"  April  17th  and  24th. 
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33)    White,  A..  " Monople.<jia  from  Passage  of  Electric  Cm-rent."     "Univ. 

M.  Mag.,"  Philadeljihia,    vol.  iv.,  p.  822. 
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triques  de  Haute  Tension."     Lyon,  p.  SO. 
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"Columbus  M.  J.."  vol.  xi.,  pp.  204-207.  * 
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vol.  xliv.,  p.  222. 


ACCIDENT   CASES. 

BY 

LAWRENCE   GODKIN,  Esq. 


The  term  "  accident  cases  "  is  tlie  colloquial  leijal  expression  for  actions 
iDvoiig'ht  to  recover  daiiiai>'cs  for  personal  injuries  wliicli  it  is  claimed  were 
the  result  of  the  defendant's  negligence.  The  greater  number  of  these 
actions  are  brought  against  common-carrier  cori^orations  or  the  o'UTiers 
or  occupants  of  i)remises  upon  Avhicli  the  accident  occurred.  Wh:^n  it  is 
remembered  that  probably  half  the  jury  cases  tried  in  the  courts  of  the 
State  of  New  York  alone,  in  any  one  year,  are  actions  for  personal  inju- 
ries resulting  from  alleged  negligence,  and  that  in  almost  aR  such  ac- 
tions one  or  more  medical  experts  are  called  to  testify  in  regard  to 
the  plaintiff's  injuries,  it  is  apparent  what  an  important  part  medical 
testimony  must  play  in  this  large  field  of  litigation.  Medical  experts 
in  these  cases  are  generally  called  to  testify  as  to  the  probable  effect 
of  wounds  and  injmies  in  respect  to  their  duration,  extent,  and  residt 
upon  the  general  health  or  capacity  for  mental  or  pliysi<:'al  work,  of 
the  injured  person ;  and  in  some  jurisdictions  the  ser\dces  of  the  ex- 
perts may  be  called  upon,  by  legal  procedure,  before  the  trial.  One  of 
the  most  interesting  questions  which  this  class  of  cases  has  created  has 
had  public  attention  recently  directed  to  it  by  the  passage  of  a  statute 
of  the  State  of  New  Yoi-k  (L.  1893,  chap.  721)  providing  that  in  an  action 
for  personal  injuries  the  court  may,  and  in  cei-tain  cases  must,  grant  an 
order  compelling  the  x^h^intiff  to  submit,  before  trial,  to  a  physical  ex- 
amination l)y  one  or  m(n'e  physicians  or  surgeons.  It  is  left  to  the  dis- 
cretion of  the  court  whether  or  not  to  grant  such  an  examination,  unless 
the  defendant  shall  present  to  the  com't  satisfactory  e^•idence  •'  that  he  is 
ignorant  of  the  nature  and  extent  of  the  injmies  complained  of."  This 
statute  has  come  up  for  construction  several  times  during  the  past  year 
and  has  l)een  the  cause  of  nnicli  discussion ;  and  in  a  recent  case  iu 
which  a  female  infant  sued  the  Manhattan  Elevated  Railway  in  the  City 
of  New  York,  and  an  order  was  obtained  for  her  examination  by  a  x>hysi- 
cian  b(»fore  trial,  the  statute  was  sharply  attacked  as  an  unconstitutional 
invasion  of  personal  rights  and  the  sanctity  of  the  person,  and  was  an- 
imadverted upon  by  the  court ;  but  its  constitutionality  has  been  thus  far 
upheld.  According  to  the  procedure  under  the  New  York  statute  the 
physician  asks  questions  of  the  plaintiff,  makes  a  physical  examination, 
and  reports  his  conclusion  in  wi'iting.  This  report  is  filed  and  may  be 
used  by  either  party  on  the  trial.  It  certainly  seems  as  if  this  statute 
would  prove  a  salutary  measure  and  tend  to  check  the  practice  of  bring- 
ing suits  for  large  damages  for  very  trifiing  or  non-existing  injuries. 

377 


378  ^   SYSTEM   OF  LEGAL  MEDICLXE. 

But  the  right  to  sueli  an  examination  lias  been  lield  by  the  Supreme  Court 
of  the  United  States  not  to  exist  at  common  law,  and  Mr.  Justice  Gray, 
in  his  opinion  in  the  case  of  the  Union  Pacific  Railway  Co.  vs.  Botsford, 
141  U.  S.  250,  says :  "  The  inviolability  of  the  person  is  as  much  invaded 
by  a  compulsory  stripping  and  exposm-e  as  by  a  blow.  To  compel  any 
one,  and  especially  a  woman,  to  lay  bare  the  body,  or  to  submit  it  to  the 
touch  of  a  stranger,  without  lawfiil  authority,  is  an  indignity,  an  assault, 
and  a  ti'espass."  The  rule  was  the  same  in  New  York  previous  to  the 
passage  of  the  statute  above  mentioned.*  But  in  the  States  of  Iowa,  Ohio, 
Kansas,  Wisconsin,  Minnesota,  Nebraska,  Missouri,  Ai-kansas,  Texas^ 
Georgia,  and  Alabama  it  has  1:)een  the  jjractice  of  the  court  to  gi-ant  or- 
ders compelling  the  plaintiff  to  submit  to  a  physical  examination  before 
trial.  It  is  probable  that  in  those  States  the  j^laintiif  would  also  be  com- 
pelled to  submit  to  a  physical  examination  at  the  trial.  But  in  New 
York,  even  since  the  passage  of  the  act  of  1893  before  alluded  to,  such 
an  examination  cannot  be  compelled  at  the  trial.  The  plaintiff  may  be 
requested  to  submit  to  such  an  examination,  and  if  he  refuse  his  refusal 
may  be  considered  by  the  juiy  as  bearing  on  his  good  faith,  but  he  can- 
not be  compelled  to  undergo  it.  In  the  Union  Pacific  Railway  case  before 
cited  Justices  Brewer  and  Brown  dissented  \agorously  from  the  conclu- 
sion reached  by  the  majority  of  the  com-t,  and  enunciated  by  Justice 
Gray,  and  said : 

"  It  seems  strange  that  a  plamtiff  may,  in  the  presence  of  a  juiy,  be 
jiermitted  to  roll  up  his  sleeve  and  disclose  on  his  arm  a  wound  of  which 
he  testifies ;  but  when  he  testifies  as  to  the  existence  of  such  a  wound  the 
court,  though  persuaded  that  he  is  perjuring  himself,  cannot  require  him 
to  roll  up  his  sleeve  and  thus  make  manifest  the  truth,  nor  require  him  in 
the  like  interest  of  truth  to  step  into  an  adjoining  room  and  lay  bare 
his  aitn  to  the  inspection  of  sui'geons.  It  is  said  that  there  is  a  sanctity 
of  the  person  which  may  not  be  outraged.  We  believe  that  truth  and 
justice  are  more  sacred  than  any  personal  consideration ;  and  if  in  other 
cases,  in  the  interests  of  justice  or  from  considerations  of  mercy,  the 
coui'ts  may,  as  they  often  do,  require  such  personal  examination,  why 
should  they  not  exercise  the  same  power  in  cases  like  this,  to  prevent 
wi'ong  and  injustice  ? " 

An  analog^'  to  the  case  of  compelling  an  examination  of  the  person  of 
the  plaintiff  in  actions  for  personal  injuries  is  to  be  found  in  the  law  of 
divorce.  In  actions  for  a  di^'orce  or  for  a  decree  of  nullity  on  the  ground 
of  incapacity  to  consummate  the  marriage,  it  is  the  practice  in  England, 
Scotland,  France,  and  generally  in  the  American  States,  where  the  evi- 
dence is  necessary,  and  can  be  obtained  in  no  other  way,  for  the  court  to 
order  an  inspection  of  the  person  by  medical  exi^erts.  The  same  ob- 
jections have  been  lu-ged  in  divorce  cases  to  such  inspections  as  have 
been  urged  to  an  examination  in  actions  for  damages  for  personal  inju- 
ries, and  as  far  as  the  ^■iolation  of  the  sanctity  of  the  person  is  concerned 
the  objection  to  an  examination  in  di^'orce  cases  is  more  weighty,  for 
the  reason  that  the  intrusion  and  violation  of  the  subject's  modesty  are 
greater.  But  tlie  necessity,  it  may  be  said,  is  also  gi-eater.  "  It  has  been 
said,"  remarked  Lord  StowcU.  '•  that  these  modes  resorted  to  for  proof  on 
these  occasions  are  offensive  to  natural  modesty.      But  nature  has  pro- 

*  McQuiyan  vs.  D.,  L.  cf-  W.  B.  IL  Co.,  129  N.  Y.  50. 


ACCIDENT  CASES.  379 

vided  no  other  ineans ;  and  we  must  he  under  the  necessity  of  saying  that 
all  relief  is  denied  or  of  a[)plying  the  means  within  our  power.  The 
court  must  not  saerifice  justice  to  notions  of  its  own."  * 

Even  in  a  case  where  a  husband  sued  for  divorce  on  the  ground  of 
the  phj^sical  incapacity  of  his  wife,  and  his  bill  was  taken  for  confessed, 
that  is  to  say,  the  wife  interposed  no  defense,  Chancellor  Walworth  of 
New  York  ordered  an  exandnation  of  the  defendant  ]>y  surgeons  and 
matrons,  and  a  report  to  the  court.  And  that  learned  jurist,  in  discussing 
tlie  application,  said:  "Investigations  of  the  kind  are  always  indelicate, 
and  tlie  mode  of  proof  to  which  resort  must  of  necessity  be  had  must 
frequently  be  very  distressing  to  the  feelings  of  parties.  This  court, 
however,  is  not  at  liljerty  to  decline  jurisdiction  in  such  a  case,  Imt  nnist 
proceed  to  the  examination  and  decision  thereof  in  the  manner  requu-ed 
l3y  law,  if  the  injured  party  thinks  proper  to  insist  iq)on  his  legal  rights."  t 

In  many  actions  for  personal  injuries  the  plaintilf  greatly  exaggerates 
his  injuries,  even  if  he  does  not  perjiu-e  himself  about  them,  and  a  medi- 
cal examination,  conducted  under  proper  safeguards  and  restrictions, 
would  seem  a  wise  check  upon  the  temptation  to  such  exaggerations  or 
perjuries.  And  in  connection  with  the  natural  anxiety  of  the  phiintitf  to 
make  his  condition  out  as  bad  as  possible,  a  story  is  told  of  an  action 
for  personal  injuries  in  the  New  York  courts,  in  which  the  jjlaintift"  tes- 
tified that  his  right  arm  had  been  so  injured  that  he  was  unaljle  to  raise 
it  any  longer  to  a  horizontal  position.  Upon  cross-examination  the  de- 
fendant's counsel  asked  him  to  indicate  how  high  he  could  now  raise  his 
arm.  "  Only  so  high,"  replied  the  witness,  lifting  his  arm  with  apparent 
diificulty  a  few  inches  from  his  side.  "  And  how  high  could  3'ou  raise  it 
before  this  unfortunate  occurrence?"  said  the  lawyer  suddenly.  "So 
high,"  replied  the  witness,  raising  this  same  injured  arm  above  his  head 
with  ease. 

When  it  comes  to  the  actual  trial  of  actions  for  personal  injui'ies  there 
are  two  difficult  questions,  to  the  solution  of  which  the  testimony  of  the 
medical  expert  may  be  directed.  One  of  these  is  how  far  the  defendant's 
negligence  is  responsible  for  some  subsequently  developed  infirmity  or 
disease,  or,  in  other  words,  how  far  a  given  injury  may  be  said  to  be  the 
•natural  and  proximate  cause  of  a  subsequently  developed  condition,  and 
therefore  render  the  defendant  liable  tov  that  contiition.  The  general 
rule  is  easily  stated — to  wit,  if  the  subsequent  disease  or  infirmity  is  one 
which  would  occur  as  the  natural  result  of  the  injury,  and  it  is  not  shown 
that  any  other  independent  cause  existed  of  which  it  might  have  been 
the  result,  then  the  author  of  tlie  original  injury  is  lial)le  for  the  subse- 
quent disease  or  infirmity.  But,  like  all  general  rules  of  law,  the  diificulty 
of  this  rule  lies  in  applying  it  to  particular  states  of  facts.  Some  illustra- 
tions may  be  useful.  The  question  has  frequently  arisen  where,  in  the 
case  of  women,  it  is  claimed  that  a  miscarriage  is  the  ultimate  result  of 
the  shock  of  an  accident,  though  not  of  any  direct  physical  injury. 

A  pregnant  woman  was  dri^dng  with  her  brother  over  a  defective 
bridge.  The  hind  feet  of  the  horses  went  through  the  bridge.  The  woman 
got  out  of  the  carriage  and  went  for  help,  and  claimed  that  her  exertion 
in  so  doing  and  her  fright  brought  on  a  miscarriage.     It  was  left  to  the 

*  Brif/f/ii  vs.  M<»-f/<ni,  3  Phillim,  325. 

t  Dvvanhcicih  vs.  J)er(i)ib(if/li,  5  Paige,  554. 


380  ^  SYSTEM  OF  LEGAL  MEDICIXE. 

jmy  to  say  whether  the  accident  was  the  natural  and  proximate  cause  of 
the  miscarriage*  And  so  where  a  railway  train  was  backed  oft:  the  rails 
thi'ough  a  fence  and  into  the  plaintiff's  porch — she  being  upstairs  in  the 
house  at  the  time — and  two  days  later  she  had  a  miscarriage,  it  was  held 
that  it  was  proper  to  leave  it  to  the  jury  to  say  whether  there  was  a  suf- 
ficient proximate  connection  between  the  accident  and  the  miscarriage 
to  warrant  a  recovery.t  These  cases  are  also  illustrations  of  the  rule  that 
it  is  not  necessary,  to  warrant  a  recovery,  that  the  disease  or  infirmity 
should  have  been  the  result  of  actual  physical  contact  with  the  medium 
of  the  neghgence.  But  an  instance  in  which  it  was  sought  to  cany  this 
liabihty  for  miscarriage  a  httle  too  far  is  to  be  found  in  a  case  in  Illinois, 
where  the  defendant  went  to  his  neighbor's  house  and  used  violent^ 
threatening,  and  abusive  language  to  the  plaintiff's  husband  in  the  hear- 
ing, but  not  in  sight,  of  the  plaintiff,  as  a  result  of  which,  through  fright^ 
the  i)laintiff  had  a  miscarriage.  The  court  very  properly,  it  would  seem, 
held  that  the  injury  in  question,  not  being  one  which  the  defendant  could, 
reasonably  be  expected  to  anticij^ate  as  likely  to  ensue  from  his  conduct, 
could  not,  therefore,  be  regarded  as  the  natural  consequence  thereof,  for 
which  the  defendant  could  be  held  responsible. 

In  a  case  in  which  a  boy  sued  the  city  of  Ripon,  Wis.,  for  damages 
for  faUing  on  a  defective  •  sidewalk  and  injuring  Ms  arm  it  was  shown 
that  the  ultimate  result  to  the  arm  was  that  the  humerus  was  in  a  necrosed 
condition  nearly  its  whole  lengih,  and  that  there  was  a  running  sore  on 
the  arm.  It  was  also  shown  that  the  boy  was  scrofulous,  and  it  was  con- 
tended for  the  defense  that  the  damage  to  the  arm  was  principally  the 
result  of  the  plaintiff's  condition  at  the  time  of  the  accident,  and  that  the 
defendant's  negligence  was  not,  therefore,  the  proximate  cause  of  the 
whole  injury  for  which  the  plaintiff  i-ecovered.  The  coui't,  however,  held 
in  effect  that  the  sidewalks  of  a  city  are  for  the  use  of  the  scrofulous  as- 
weU  as  tlie  sound,  and  that  if  a  sick  person  faUs  on  a  defective  sidewalk 
so  much  the  worse  for  the  city,  and  upheld  the  plaintiff's  contention  that 
the  negligence  of  the  defendant  was  the  proximate  cause  of  the  whole  in- 
jury for  which  the  plaintiff  recovered  damages.f 

The  other  difficult  question,  which  is,  in  a  sense,  the  converse  of 
the  foregoing,  is  how  far  the  defendant's  negligence  is  responsible  for 
an  existing  condition  where  a  disease  or  injuiy  existed  previous  to  the 
neghgence  complained  of,  and  is  claimed  to  have  been  aggravated 
by  that  negligence.  For  instance,  the  fact  that  a  person  suffering  injimes 
from  the  negligence  of  a  railroad  comj^any  is  afflicted  with  a  disease  of 
which  he  must  ultimately  die,  will  not  relieve  the  raih'oad  company  of 
responsibiUty  for  injuries  which  hasten  his  death.§  And  the  fact  that  a 
person  was  suffering  from  Bright's  disease  at  the  time  he  was  injured 
does  not  j)revent  his  recovery,  although  the  injury  was  aggravated  by  the 
disease.!!  And  if  the  plaintiff  had  a  tendency  or  predisposition  to  can- 
cer this  will  not  reheve  the  defendant  from  lialiility  for  a  cancer  which 
develops  as  the  result  of  an  injury.^]     So  a  person  i)redisposed  to  mala- 

*  OUvcr  vs.  ToKn  of  Laralle,  36  Wis.  592. 

+  Chicago  i^-  Northiccstcrn  R)/.  Co.  vs.  Hioicrhcrg,  16  Bradwell,  387. 

t  Stewart  vs.  Citi/  of  Ripon,' 38  Wis.  584. 

§  Louisville  ^-  JV.  li.  Co.  vs.  Jones,  83  Ala.  376. 

II  Loitisrille  X.  J.  i?.  li.  vs.  Sni/dcr,  117  lud.  435. 

il  Baltimore  R.  Co.  vs.  Kemj),  61  Md.  74. 


ACCIDENT  CASES.  381 

rial,  scrofulous,  or  rheumatic  tendencies,  Init  otherwise  in  good  health, 
may  recover  dama<''es  for  the  development  of  such  tendencies  l)y  a  nefjli- 
giait  injury.*  Nor  do  previous  fnu'tures  affect  the  mea.sure  of  damages 
for  a  sul)sc(|uent  fracture  caused  by  the  defendant's  negligence.t  And 
where  an  injury  to  a  child  was  aggravated  by  a  latent  hereditary  hyster- 
ical diathesis  which  might  never  have  been  developed  but  for  the  acci- 
dent, it  was  held  that  the  entire  damages  were  recoverable  from  the  party 
whose  negligence  caused  the  in j my 4  ^t  has  also  been  held  that  a  plaintiff 
could  recover  for  hernia  resulting  nine  months  after  a  scalding  by  steam 
escaping  from  a  locomotive,  and  for  cancer  resulting  three  months  after 
a  blow  on  the  breast. 

If,  however,  any  casual  or  unexpected  causes  intervene  between  the  acts 
which  injure  the  plaintiff  and  his  ultimate  coudition,  and  these  causes  are 
such  as  could  not  have  been  reasonably  foreseen  in  the  light  of  attending 
circumstances,  the  party  causing  the  first  injury  will  not  be  liable  for  the 
ultimate  result.  For  instance,  a  man  was  hurt  in  a  railway  collision  and 
became  insane  as  a  result  of  it.  Eight  months  after  the  accident  he  com- 
mitted suicide.  His  personal  representatives  sued  the  railway  company 
for  damages  for  his  death.  The  Supreme  Court  of  the  United  States  held 
that  they  could  not  recover.§  Of  course  in  this  instance  the  chain  of  rea- 
soning l)y  which  it  was  sought  to  hold  the  railway  company  liable  was 
just  as  logical  and  contained  no  more  links  than  some  of  the  eases  before 
cited  in  which  the  defendant  was  held  hable ;  but  there  must  be  a  line 
drawn  somewhere,  and  the  place  to  draw  the  line  is,  after  all,  to  be 
pointed  out  by  common  sense  rather  than  by  any  hard-and-fast  rule  of 
law. 

Suppose,  however,  one  of  the  possible  or  probable  intervening  factors- 
to  produce  the  ultimate  result  has  been  the  malpractice  of  the  physician 
or  surgeon  called  in  to  treat  the  original  injiuy :  must  the  defendant 
bear  the  burden  of  this  too  f  The  answer  is  that  if  the  injured  person 
has  used  reasonable  care  and  judgment  in  the  selection  of  his  physician, 
tlie  defendant  must  suffer  the  consequences  of  the  ignorance  or  want  of 
skill  of  that  physician.  The  patient  is  not  obliged  to  call  in  the  most 
eminent  physician  or  surgeon,  of  the  highest  professional  skill  and  most 
iufallible  judgment,  before  he  can  hold  the  defendant  lial)le  for  the  con- 
dition in  which  he  is  left  at  the  end  of  his  medical  treatment.  If,  for 
instance,  a  num  who  is  injured  in  a  railway  accident,  and  uses  ordinary 
judgment  in  the  selection  of  his  physician,  is  told  by  his  physician  to- 
take  exercise,  and  it  is  proved  that  if  he  had  not  taken  exercise  he  would 
have  recovered  sooner,  this  will  afford  no  defense  to  the  railway  com- 
panyo  The  reason  for  this  rule,  as  given  by  the  Supreme  Com't  of 
Maine,  is  this :  "  In  the  present  imperfect  state  of  the  medical  science, 
and  amidst  the  conflicting  theories  of  medical  men,  as  well  as  the  uncer- 
tain reliance  to  be  placed  upon  the  different  modes  of  treating  injuries 
and  diseases,  it  would  not  be  difficidt  to  make  it  doul)tful,  in  a  given  case, 
it'  tlie  professional  treatment  might  not  have  been  improved  or  was  un- 
skillful, and  thus  a  way  of  escape  niiglit  be  prepared  for  wrong-doers 
from  the  legitimate  and  legal  consequences  of  tlieii*  negligence  or  mis- 

*  Loiii.<tviUe  /?.  R.  Co.  vs.  Fnlrci/.  104  Ind.  409. 

t  Drciss  vs.  Frederick;  73  Tex.  460. 

t  Lnplciiie  vs.  Morqan's  L.  .f-  T.  li.  Co..  30  La.  Ann.  661, 

$  ScUeffer  vs.  liailwail  Co.,  105  U.  S.  249. 


382  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

conduct.   The  principle,  therefore,  of  holding  the  defendants  responsible, 
is  founded  in  sound  reasons  of  public  policy."* 

In  case  of  the  death  of  the  injured  person,  and  an  action  brought  by 
his  or  her  personal  representatives  to  recover  damages  therefor,  it  is  ob- 
vious that  the  elements  entering  into  the  question  of  the  amount  of 
damages  will  be  different  from  those  which  may  be  considered  by  the 
jmy  in  an  action  brought  hy  the  injured  person  himself.  At  common 
law  the  right  of  action  for  injuries  resulting  in  death  perished  with  the 
deceased,  and  the  right  given  to  the  personal  representatives  of  the  de- 
ceased to  sue  is  entii'el}'  the  creation  of  statute ;  and  the  elements,  there- 
fore, which  enter  into  the  question  of  damages  in  such  cases  are  controlled 
by  the  construction  which  is  put  upon  the  statute  of  the  jurisdiction  in 
which  the  suit  is  brought.  For  instance,  under  Lord  Campbell's  Act, 
which  is  the  British  statute  giving  a  right  of  action  for  injuries  resulting 
in  death,  the  jury  is  limited  to  the  actual  pecuniary  injuiy  done  to  the 
family  of  the  person  kiUed,  and  can  give  nothing  by  way  of  solatium  for 
their  grief  and  injiu^ed  feelings,  or  to  compensate  them  for  the  loss  of 
society  or  companionshij)  which  they  have  suffered,  nor  can  anji^hing  be 
allowed  in  such  action  on  account  of  the  j)hysical  or  mental  suffering  of 
the  deceased;  and  the  riile  is  substantially  the  same  under  the  New  York 
statute,  so  that  where  the  injm-ed  person  dies  the  office  of  expert  testi- 
mony will  l3e  limited  to  the  question  of  whether,  in  a  case  where  tliere  is 
any  doubt,  the  death  was  the  result  of  the  injiuy.  Where,  however,  the 
injuries  do  not  result  fatally,  and  the  action  was  brought  by  the  injui-ed 
person  liimself ,  the  elements  Avhich  the  jiuy  may  consider  in  deteiinining 
the  amount  of  damages  are  the  impaii-ed  capacit}'  of  the  plaintiff  to  earn 
monej^,  the  cost  of  Ms  cure,  and  his  physical  and  mental  pain  and  suffer- 
ing. In  all  these  matters  the  testimony  of  physicians  may  be  material. 
In  estimating  the  loss  of  earning  power,  just  as  in  determining  how  far 
the  defendant's  negligence  is  responsible  for  subsequent^  developed  in- 
firmity, the  rules  of  common  sense  must  be  applied,  and  the  decrease  in 
earning  power  for  which  there  may  be  a  recover}^  must  be  such  as  is 
reasonably  certain  to  resiilt  from  the  injury  in  ordinary  course  of  nature, 
and  not  such  as  may  be  the  possible  consequence  of  the  injury.  In  a 
leading  case  in  New  York,  Dr.  Spitzka,  who  had  examined  the  plaintiff, 
who  was  a  boj^  who  had  been  injured  in  a  railway  accident,  was  asked  as 
to  the  pei-manency  of  this  condition  of  the  plaintiff,  and  he  answered  that 
it  was  very  likely  to  be  permanent.  He  also  stated  that  the  plaintiff  was 
liable  to  retain  the  greater  part  of  the  symptoms  which  he  had,  if  he  did 
not  develop  worse  signs.  He  was  then  asked  what  he  referred  to  by  his 
statement  that  the  boy's  condition  might  develop  into  worse  signs  or  con- 
ditions, and  he  answered,  "  A  patient  sustaining  such  injuries  and  pre- 
senting such  premonitory  signs  may  develoj)  traimiatic  insanity  or  men- 
ingitis or  progressive  dementia  or  epilepsy,  with  its  results."  The  question 
was  objected  to  as  speculative  and  hypothetical,  but  was  allowed,  and  the 
Court  of  Api^eals,  in  reversing  the  judgment  and  ordering  a  new  trial, 
said :  ''  The  door  was  opened  for  the  jury,  in  estimating  the  damages,  to 
include  compensation  for  the  mere  hazard  to  which  the  plaintiff'  was 
claimed  to  be  exposed  of  being  afflicted  ^\dth  the  terrible  disorders,  or 
some  of  them,  enumerated  in  the  answer,"  and  "  to  entitle  a  plaintiff  to 

*  Stover  vs.  BlueliiU,  51  Me.  442. 


ACCIDENT  CASES.  383 

recover  proseiit  damages  for  apprehended  future  consequences  there  must 
be  sueli  a  degree  of  probahility  of  their  oeeui-ring  as  amounts  to  a  reason- 
able certainty  that  they  will  result  from  the  original  injui-y."* 

There  is  an  English  ease,  illustrating  some  of  the  rules  of  law  by  wliieh 
the  jury  are  to  be  guided  in  deciding  upon  the  amount  of  damages  for 
personal  injuries,  which  may  have  a  peculiar  interest  to  members  of  tlie 
medical  profession,  owing  to  the  fact  that  the  plaintiff  was  himself  an 
eminent  London  physician.  To  lawyers  the  case  is  of  imi)ortanee  Ijecause 
it  is  a  h.^ading  English  case  on  the  subject,  and  was  twice  tried  before  a 
jury  and  twice  ai)pealed,  and  the  i)rinciples  involved  were  \ery  thoroughly 
discussed  l:>y  the  appellate  courts.  The  plaintiff.  Dr.  Phillii)s,  was  an 
eminent  London  physician  of  middle  age  and  robust  health,  earning  an 
income  from  the  practice  of  his  profession  of  about  £5000  a  year.  He 
was  injured  in  a  railway  accident  and  his  health  irreparably  impaired  to 
such  a  degree  as  to  render  life  a  burden  and  a  source  of  the  utmost  misery. 
His  condition,  as  Lord  Chief -Justice  Coekburn  put  it,  was  at  once  helpless 
and  hopeless.  The  expenses  incurred  by  reason  of  the  accident  had  al- 
ready, at  the  time  of  the  first  trial,  amounted  to  £1000,  and  medical  at- 
tendance to  still  more,  and  the  latter  was  likely  to  be  for  a  hmg  time 
necessary.  He  had  already  lost  his  income  for  the  period  of  sixteen 
months  which  liad  elaj^sed  between  the  time  of  the  accident  and  the 
trial.  On  the  first  trial  the  juiy  gave  him  £7000  damages.  The  Coiu't 
of  Queen's  Bench  reversed  the  judgment  and  ordered  a  new  trial  on  the 
ground  of  the  insufficiency  of  the  verdict,  and  this  reversal  was  afiii-med 
by  the  Court  of  Appeal.     Lord  Coekburn  said : 

"  But  w^e  think  that  a  jury  cannot  be  said  to  take  a  reasonable  view 
of  the  case  unless  they  consider  and  take  into  account  all  the  heads  of 
damage  in  resjDect  of  which,  a  plaintiff  complaining  of  a  personal  injury 
is  entitled  to  compensation.  These  are  the  bodily  injmy  sustained  ;  the 
pain  undergone ;  the  effect  on  the  health  of  the  sufferer,  according  to  its 
degrees  and  its  probable  duration  as  likely  to  be  temporary  or  permanent ; 
the  expenses  incidental  to  attempts  to  effect  a  cure  or  to  lessen  the  amount 
of  injury ;  the  pecuniary  loss  sustained  through  inability  to  attend  to  a 
profession  or  business,  as  to  which,  again,  the  injury  may  be  of  a  tempo- 
.  rary  cliaracter  or  may  be  such  as  to  incapacitate  the  party  for  the  remainder 
of  his  life.  If  a  jury  have  taken  all  these  elements  of  damage  into  con- 
sideration, and  have  awarded  what  they  deemed  to  be  fail'  and  reasonable 
compensation  under  all  the  circumstances  of  the  case,  a  court  ought  not, 
unless  under  very  exceptional  circumstances,  to  disturb  their  verdict. 
But  looking  to  the  figure  in  the  present  case  it  seems  to  us  that  the  jmy 
must  have  omitted  to  take  into  account  some  of  the  heads  of  damage 
which  w^n-e  properly  involved  in  the  plaintiff's  claim."  t 

On  the  second  trial,  before  Lord  Chief-Justice  Coleridge,  the  jury  found 
a  verdict  for  £10,000.  This  time  the  defendant  appealed  and  the  case 
again  went  to  the  Court  of  Appeal,  but  the  judgment  was  affirmed.  On 
the  second  appeal,  in  discussing  the  evidence  upon  which  to  base  compen- 
sation for  the  loss  of  a  professional  or  trade  income.  Lord  Justice  Brett 
said : 

''  It  has  been  in  effect  suggested  by  the  counsel  for  the  defendants  that 

*  Sirnlim  vs.  .Y.  T..  L.  E.  .f-  W.  JR.  B.  Co..  9G  N.  Y.  305. 
t  Fhilli_ps  vs.  Soutlncestern  By.  Co.,  4  Q.  B.  D.  406. 


584  ^   SYSTEM   OF  LEGAL  MEDICINE. 

the  amount  of  the  income  at  the  time  of  the  accident  ought  not  to  be 
taken  into  account.  This  suggestion  seems  to  me  to  be  erroneous.  .  .  .' 
If  no  accident  had  hapj)enecl,  nevertheless  many  circumstances  might  have 
happened  to  prevent  the  j)laintiif  from  earning  his  j)rofessional  income. 
He  may  be  disabled  by  illness,  he  is  subject  to  the  ordinar}-  accidents  and 
vicissitudes  of  life,  and  if  all  those  circumstances  of  which  no  evidence 
can  be  given  are  looked  at  it  would  be  imj^ossible  to  exactl}^  estimate 
them.  Yet  if  the  jmy  whoUy  pass  over  them  they  will  go  wrong,  because 
those  accidents  and  ^dcissitudes  ought  to  be  taken  into  account.  It  is 
true  that  the  chances  of  life  cannot  be  accurately  calculated,  but  the  judge 
must  tell  the  jury  to  consider  them  in  order  that  they  may  give  a  fair 
and  reasonable  compensation." 

The  plaintiff  can  alwa^-s  recover  the  cost  of  medical  attention,  nui'sing, 
and  all  ordinary  and  reasonable  expenses  which  he  has  incurred  by  reason 
of  his  sickness,  and  it  has  been  held  to  l)e  no  defense  to  a  recovery  for 
money  paid  to  a  nui'se  that  the  plaintiff  had  a  family  capable  of  taking 
care  of  liim.  This  last  defense  in  these  days  of  trained  nm-sing  strikes 
one  as  being  a  httle  strained,  and  evidently  struck  the  court  so.*  It  has 
even  been  held  that  a  plaintiff  may  recover  the  value  of  medical  ser\dces 
gratuitously  rendered,  the  reason  being  that  these  ser\T.ces  were  rendered 
for  the  benefit  of  the  plaintiff  and  not  for  the  benefit  of  the  defendant, 
and  the  defendant  should  not,  therefore,  be  allowed  to  profit  by  them. 
In  one  of  the  cases  in  which  this  rule  was  enunciated  tlie  plaintiff  was  a 
physician,  and  it  was  sought  to  prove  that  it  was  a  luiiversal  custom 
among  phj^sicians  and  surgeons  not  to  charge  members  of  the  profession 
for  services  rendered,  but  the  evidence  was  held  inadmissible  as  immate- 
rial.t  The  term  "medical  services  and  expenses"  does  not  merely  in- 
clude doctors'  bids,  medicines,  and  nursing,  but  covers  also  reasonable, 
necessary,  and  judicious  trij)S  to  health-resorts;  as,  for  instance,  where  a 
person  injm-ed  in  a  railway  accident  went  to  the  Electric  Wells  in  Geor- 
gia and  the  Glenn's  Springs  in  South  Carolina  for  treatment,  he  was 
allowed  to  prove  the  expense  of  these  trips  as  part  of  his  claim4  But 
where  a  parent  sues  for  the  loss  of  ser^dces  of  a  child  as  the  residt  of  an 
accident,  he  can  recover  as  expenses  for  medical  attendance  only  those 
actually  incurred  or  immediately  necessary ;  future  and  contingent  ex- 
penses are  recoverable  only  by  the  child  and  not  by  the  parent.§ 

*  Kendall  vs.  Citii  of  Albia,  Iowa  Supreme  Court,  October  27,  1887. 
t  City  of  Indianapolis  vs.  Gaston,  58  Ind.  224. 
X  Bart  vs.  Charlotte  B.  Co.,  32  S.  C.  427. 
$  Jones  vs.  Chamherlain,  109  N,  Y.  100. 


MENTAL    DISTRESS   AS   AN   ELEMENT   OF   DAMAGE 

IN  CASES   TO  EECOVER  FOR   PERSONAL 

INJURIES. 

By  JOHN  E.  PARSONS,  Esq. 


It  is  common  experience  that  anguish  of  mind,  laceration  of  feehug, 
a  sense  of  shame,  of  indignation,  or  of  hnmihation,  anxiet}^,  distress  of 
a  sentimental  character,  are  often  more  difficult  to  bear  than  hodily  hurt. 
Where  such  injury  has  been  occasioned  by  the  fault  of  another,  the  ques- 
tion arises  whether  in  every  case  the  law  affords  redress.  The  maxim  of 
the  law  is  that  for  every  wrong  there  is  a  sufficient  remedy.  Does  this 
maxim  hold  true  in  all  cases  of  the  character  referred  to  1  The  general 
principle  is  well  estabhshed  that  in  actions  of  tort,  where  for  the  wrong- 
there  is  a  right  to  recover  damages,  mental  distress  may  be  taken  into 
■consideration  in  fixing  the  amount.  But  the  weight  of  authority  seems 
to  establish  that  when  the  injury  consists  in  distress  of  mind  alone,  or 
where  the  mental  distress  is  separate  from  and  independent  of  the  ^^a•oug, 
it  does  not  constitute  an  element  of  damage  and  ma}'  not  be  considered 
in  determining  the  amount  of  a  recovery. 

In  support  of  the  general  proposition,  Mclnf\jre  vs.  Gihlin,  131  U.  S. 
174,  is  a  receut  authority.  This  was  a  suit  to  recover  danuxges  for  the 
careless  shooting  and  wounding  of  Giblin  by  Mclntyre.  On  the  trial  the 
court  charged  the  jury  that  in  computing  the  damages  they  nught  take 
into  consideration  ''a.  fair  compensation  for  the  physical  and  niotfal  suf- 
fering caused  by  the  injury."  The  United  States  Supreme  Court,  Chief- 
Justice  Waite  delivering  the  opinion,  held  that  there  was  no  error  in 
permitting  a  recovery  for  mental  suffering.  The  court  said  that  the 
€ffe(;t  of  the  instruction  was  no  more  than  to  allo^^'  the  jury  to  give  eom- 
peusation  for  the  personal  suffering  of  the  plaintiff  caused  by  the  injurv. 

In  Hamilton  vs.  Third  Avenue  R.  R.,  53  N.  Y.  25  (1873),  the  Court  of 
Appeals  of  the  State  of  New  York  held,  where  the  plaintiff  was  forcibly 
■ejected  from  one  of  the  defendant's  cars  because  of  his  refusal  to  pay  his 
fare  a  second  time,  that  the  injury  to  his  feelings  uiiglit  be  taken' into 
consideration  by  the  jury  and  a  suitable  recouipense  giveu  therefor.  In 
Hamilton  vs.  Uno,  81  N.  Y.  IIG,  the  same  court  aflirnied  the  decision  of 
the  General  Term  of  the  Supreme  Court  {Hamilton  ys.Uno,  16  Hun,  599), 
holding  in  an  action  for  libel  that,  in  a  case  where  damage  had  been 
shown,  injury  to  feelings  ndght  be  treated  as  a  proper  subject  for  con- 
sideration. 

Other  illustrations  of  tlie  general  rule  will  be  found  in  cases  decided 

385 


386  ^   SYSTEM  OF  LEGAL   MEDIC IXE. 

by  the  Euglisli  courts  and  by  the  coui'ts  of  mauy  of  the  States.  Thus  in 
Blal-e  vs.  Midland  Raihvay  Co.,  18  Q.  B.  93,  Coleridge,  J.,  said:  ''When 
an  action  is  brought  by  an  individual  for  a  personal  ^vi'ong,  the  jury,  in 
assessing  the  damages,  can  with  little  ditficulty  award  him  a  solatium  for 
his  mental  sutferings  alone,  with  an  indemnity  for  his  pecuniary  loss." 
Godeau  vs.  Blood,  52  Vt.  251,  was  a  case  where  a  child  was  bitten  by  a 
vicious  dog.  Redfield,  J.,  said  that  the  apprehension  of  poison  from  the 
bite  of  the  dog,  and  the  fear  and  solicitude  as  to  evil  results  therefrom, 
w^ere  proper  matters  for  consideration  hj  the  jury  in  estimating  the  dam- 
ages. In  Reddles  vs.  Railway  Co.,  11  Wis.  228,  it  ajjpeared  that  one  of 
the  defendant's  engines  ran  over  a  boy  and  crushed  both  his  legs.  It 
was  held  on  appeal  that  damages  might  be  awarded  for  the  "mortifica- 
tion and  anguish  of  mind  which  he  has  suffered  and  will  suffer  in  the 
future  by  reason  of  the  mutilation  of  his  body  and  the  fact  that  he  may 
become  an  object  of  curiosity  and  ridicule  among  his  feUows."  Seger  vs. 
Toivn  of  BarA'Jiamsfead,  22  Conn.  290  ;  8herwood  vs.  Railway  Co.,  88  Mich. 
108 ;  and  Railroad  Co.  vs.  Stables,  62  111.  313,  are  similar  cases. 

Kennedy  vs.  Standard  Sugar-refining  Co.,  125  Mass.  90,  states  the  prin- 
ciple under  novel  circumstances.  Kennedy,  an  employee  of  the  defend- 
ant, fell  several  stories  and  was  killed.  The  fall  was  due  to  a  defective 
floor.  When  he  struck  the  ground  he  became  unconscious  and  remained 
so  until  death.  This  action  was  brought  by  his  administratrix.  At  nisi 
prius  the  mental  sufferings  of  the  deceased  dmlng  the  faU  were  allowed 
as  an  element  of  damage.  Morton,  J.,  on  apjDeal,  said :  "  It  may  be  true^ 
as  an  abstract  proposition  of  law,  that  if  a  man  is  precipitated  from  a 
height  by  the  negligence  of  another,  and  is  injiu'ed,  he  may  recover,  as- 
one  element  of  his  damages,  for  any  mental  suffering  he  may  prove  he 
endured  during  his  fall."  Damages  were  refused  simply  because,  Ken- 
nedy having  remained  unconscious  till  death,  there  was  no  way  of  prov- 
ing mental  suffering. 

The  cases  aU  proceed  upon  the  principle  that  where  personal  injury 
has  been  inflicted,  for  which  the  wrong-doer  can  be  made  liable,  mental 
distress  may  be  taken  into  account  as  well  as  injmy  to  person  or  char- 
acter. Some  go  to  an  extreme  length  in  permitting  a  recovery  where  it 
is  wounded  feeling,  mortification,  indignity,  or  a  sense  of  humiliation  in 
which  consists  substantially  the  entire  injury.  Thus  in  Cral'er  vs.  Rail- 
ivay  Co.,  36  Wis.  657,  it  was  held  that  a  female  passenger  on  a  railway- 
train  could  recover  for  the  sense  of  shame  and  personal  affront  which 
accompanied  the  act  of  the  conductor  of  the  train  in  placing  his  arm 
around  her  against  her  protest,  and  kissing  her.  Ob\dousl5^  in  this  case 
the  bodily  injury  was  nominal.  It  was  for  the  indignity  that  the  plaint- 
iff was  permitted  to  hold  the  company  liable.  The  extent  to  which 
courts  have  gone  in  grasping  at  the  slightest  proof  of  bodily  harm  to 
permit  a  recovery  for  distress  of  mind  occasioned  by  the  same  occurrence 
is  illustrated  by  many  cases.  Railroad  Co.  vs.  Brown,  17  Wallace,  445, 
and  Railway  Co.  vs.  Williams,  55  111.  185,  were  suits  brought  by  female 
colored  passengers  who  were  not  permitted  to  sit  in  cars  reserved  for 
ladies.  In  the  first  case  the  Supreme  Court  of  the  United  States  refused 
to  disturb  a  verdict  of  $1500,  although  the  passenger  aggrieved  was  car- 
ried safely  to  her  destination  ;  and  in  the  second  it  was  held  upon  appeal 
that  a  verdict  of  $200  was  not  excessive,  Scott,  J.,  saying:  "We  appre- 
hend that  if  the  act  is  wrongfully  and  wantonly  committed  the  party 


MENTAL   DISTRESS.  337 

may  recover,  in  addition  to  the  actual  damages,  something  for  the  indig- 
nity, vexation,  and  disgrace  to  whicli  the  party  has  been  subjected.'' 
In  Anonymous,  Minor  (iUa.),  52,  it  appeared  that  one  broke  into  the 
liouse  of  anotlier  without  a  warrant,  under  pretense  of  searching  for 
stolen  money.  The  court  said:  "He  [phiintiff]  may  have  sustained  no- 
pecuniary  h)ss,  but  the  injmy  fixes  on  liim  the  eye  of  public  suspicion,, 
inflicts  a  rankling  wound  on  his  feelings,  and  tends  to  jn-osti-ate  liis 
character."  It  was  held  tliat  for  such  injury  to  liis  feelings  the  plaintitf 
might  recover.  In  CuituuiiKj  vs.  Iiiliabifaiii.s  of  WiUiauinhKiy,  1  Cusliing,. 
451,  Metcalf,  J.,  said:  "Though  that  bodily  injury  may  have  been  very 
small,  yet  if  it  was  a  ground  of  action  within  the  statute,  and  caused 
mental  suffering  to  the  plaintiff,  that  suffering  was  a  part  of  the  injury 
for  wliicli  he  was  entitled  to  damages."  ( Vide,  also,  Curtis  vs.  Railivai/ 
Co.,  Supreme  Court  of  Iowa  (1893),  54  Northwestern  Reporter,  339  ;  117//- 
Konvs.  Railroad  Co.,  5  Wash.  621  (1893);  Chicago,  etc.,  R.  R.  Co.  vs.  Con- 
leij,  6  Indiana  Appellate  Court  Rej^orts,  9  (1892);  t'ihepard  vs.  RaiJwaij 
Co..  11  Iowa,  54  (1889) ;  The  LaJie  Erie,  etc..  Railway  Co.  vs.  Fix,  88  Ind.. 
381  (1882) ;  Chicago,  etc.,  R.  R.  Co.  vs.  Flagg,  43  111.  364  (1867).) 

What  remains  to  consider  is  the  right  to  recover  for  mer«  mental 
distress  consequent  upon  the  negligence  or  misconduct  of  another.  Upon 
this  subject  an  interesting  and  instructive  case  is  Lynch  vs.  Knight,  9  H. 
of  L.  Cas.  598.  The  case  came  to  the  House  of  Lords  from  the  Irish 
Court  of  Exchequer  Chamber.  It  was  heard  just  before  the  death  of 
Lord  Camijbell.  He  left  a  written  decision  which,  with  comments  by 
way  of  partial  dissent,  was  read  by  his  successor,  Lord  Brougham.  The- 
defendant  had  impugned  the  chastity  of  the  plaintiff's  wife  in  terms 
which  were  not  actionable  |)er  se.  The  husband  sued  in  his  own  right^ 
joining  his  wife,  and  recovered  £150  for  the  deprivation  of  her  society^ 
he  luiving  sent  her  home  to  her  parents  in  consequence  of  the  imputation 
upon  her  conduct.  All  the  judges  agreed,  there  being  no  evidence  of 
special  damage,  that  a  recovery  for  mental  suffering  could  not  be  sus- 
tained. Hyatt  vs.  Adams,  16  3Iicli.  180,  is  to  the  same  effect.  The  action 
was  brought  to  recover  damages  sustained  by  the  plaintiff  by  reason  of 
malpractice  resulting  in  the  death  of  his  yMe.  The  plaintiff  claimed 
damages  for  his  mental  agony  on  account  of  his  wife's  sufferings  for  the- 
three  days  prior  to  her  death.  Christiancy,  J.,  in  overiiiling  the  charge 
of  the  judge  below,  speaks  of  "  the  propriety  and  good  sense  of  the  rule 
which  restricts  the  right  of  action  for  mental  suffering  to  the  person  who 
has  received  the  physical  injiu-y."  Connell  vs.  Western  Union  Telegraph 
Co.,  116  Mo.  34,  deals  with  the  general  suljject  in  a  very  able  way.  The 
case  was  elaboratel_y  discussed,  all  the  leading  authorities  upon  the  sub- 
ject being  referred  to.  The  action  was  to  recover  danuiges  for  the  negli- 
gence of  the  defendant  in  failing  to  deliver  to  the  plaintiff  the  followiug^ 
telegraphic  message  sent  to  him  bv  his  wife  : 

"  Sedalia,  Mo.,  December  13, 1889.  To  Matt.  Connell,  Soldiers'  Home, 
Leavenworth,  Kansas.     Your  child  is  dving.     Marv." 

The  child  died  on  December  24,  1889.  The  plaintiff,  claiming  tliat 
the  defendant  had  negligently  failed  to  deliver  the  message,  and  that  in 
consequence  he  had  been  unable  to  attend  the  funeral  of  his  child,  brought 
suit  to  recover  among  other  things  for  the  mental  anguish  and  prostra- 
tion wliich  he  had  suffered.  The  court  held  tliat  he  could  not  recover, 
the  mental  distress  not  having  attended  upon  or  been  accompanied  by 


388  -4   SYSTEM  OF  LEGAL  MEDICINE. 

pliysieal  injury.  Tlie  same  principle  was  decided  in  Wilcox  vs.  Richmond 
d'  D.  II.  Co.,  52  Federal  Reporter,  264.  The  complaint  alleged  tliat  the 
plaintiff,  being  informed  by  telegraph  of  the  dangerons  illness  of  his 
father,  engaged  defendant  to  convey  him  to  Columbia,  S.  C,  where  his 
father  TS'as,  in  a  fixed  time,  pa;s'ing  for  the  service  $195.  The  plaintitf 
charged  that  the  defendant  refused  to  perform  its  agreement,  and  that 
as  a  consequence  he  suffered  gi-eat  distress  of  mind,  anxiety,  mortifica- 
tion, and  suspense,  for  which  he  claimed  $5000  damages.  There  was  a 
second  cause  of  action  for  the  return  of  the  $195.  The  plaintiff  was  per- 
mitted to  recover  the  latter  amount,  but  the  C'ii'cuit  Com-t  of  the  United 
States  for  the  Distiict  of  South  Carolina.  Chief-Justice  Fuller  sitting 
with  the  Circuit  Judge  and  District  Judge,  affirmed  a  decision  by  which 
it  was  held,  on  the  authority  of  Lynch  vs.  Knight,  that  for  mental  pain 
alone,  unattended  by  injuiy  to  the  person,  caused  liy  simple  neghgence, 
an  action  could  not  be  sustained. 
-  Victoria  Baihvay  Commission  vs.  Coultas,  L.  E.,  13  App.  Cas.  222  (1888), 
privy  council  on  appeal  from  Supreme  Court  of  Victoria,  is  a  recent 
case.  A  female  crossing  a  railroad  track  in  a  wagon  just  escaped  being 
dashed  into  by  a  jjassing  ti'ain,  in  consequence  of  the  negligence  of  an 
employee.  She  received  a  severe  nervous  shock  fi-om  ft-ight,  and  the  con- 
sequence of  the  fright  was  an  attack  of  illness.  On  appeal  it  was  held 
tjiat  for  this  she  could  not  recover,  the  damages  being  too  remote.  Sir 
Ei chard  Couch,  in  delivering  the  opinion  of  the  court,  said :  "  Damages 
arising  fi'om  mere  sudden  teiTor  unaccompanied  by  any  actual  physical 
injury,  but  occasioning  a  neiwous  or  mental  shock,  cannot  luider  such 
circxun stances,  their  lordships  think,  be  considered  a  consequence  which 
in  the  ordinary  coiu'se  of  things  would  flow  from  the  neghgence  of  the 
gate-keeper."  To  the  same  effect  are  Eicing  vs.  Baihvay  Co.,  147  Pa. 
St.,  40 :  City  of  Salina  vs.  Trosper,  27  Kan.  544 ;  Wymnn  vs.  Leavitt, 
71  Me.  227.  In  EaUroad  Co.  vs.  Staples,  62  HI.  313,  it  appeared  that 
Stables,  while  crossing  a  raih'oad  track,  was  struck  by  a  passing  train. 
His  wagon  was  broken  and  he  was  severely  injui^ed.  The  coui-t  held 
that  for  his  mental  sufferings  Stables  could  recover,  saying  :  "  The  mental 
anguish  which  would  not  be  proper  to  be  considered  is  where  it  is  not 
connected  with  the  bodily  injury,,  but  was  caused  by  some  mental  con- 
ception not  arising  from  the  physical  injuiy." 

It  is  proper  to  state  that  although  the  cases  cited  and  others  seem  to 
settle  the  rule  that  for  mere  mental  distress  there  can  be  no  recovery, 
their  authority-  has  not  gone  imquestioned.  In  Bell  vs.  The  Great  Xorth- 
ern  Baihvay  Co.,  26  L.  E.,  Ireland,  428  (1890),  the  com-t  expressly  refused 
to  follow  Victoria  Bailtvay  Commission  vs.  Coultas.  The  plaintiff  was  put 
in  gi'eat  fright  by  the  anticipation  of  a  collision.  She  suffered  fi-om 
nervous  shock  and  ill  health  in  consequence.  She  sustained  no  bodily 
injiuy.  It  was  held  on  appeal  that,  since  the  fright  was  the  direct  conse- 
quence of  the  occurrence  and  the  plaintiff's  ill  health  the  consequence  of 
the  fright,  damages  might  be  recovered  for  impairment  of  liealth. 

And  in  some  of  the  States  it  has  been  stoutly  maintained  that  there 
might  be  a  recovery  for  neiwous  shock  or  mental  distress  where  there 
was  no  bodily  or  pecuniary  loss.  Hale  vs.  Bonner,  82  Tex.  33,  was  such 
a  case.  The  plaintiff  sued  to  recover  damages  for  breach  of  contract  on 
the  part  of  the  defendant  in  failing  to  deliver  promptly  the  body  of  her 
deceased  husband.     The  contract  was  for  carriage  from  San  Antonio  to 


MENTAL  DISTRESS.  389 

Jefferson.  Wlien  the  train  arrived  at  Jefferson,  where  many  friend^ 
Avere  wjiiting-  to  accomjjany  the  body  home,  it  Avas  not  on  ))oard,  to  phiint- 
iff's  great  distress  of  mind.  When  tlie  body  did  arrive  it  was  in  an 
ad yan(!ed  stage  of  decomposition,  wlueli  caused  the  i)laintitt'  a(kliti()nal 
pain  of  mind.  A  demurrer  was  sustained  in  the  court  l)eh)w.  On  ap]jeal 
the  ju(]gment  entered  on  tlie  demurrer  was  reversed.  M^estern  Union 
Teleijnqjh  Co.  vs.  Xcwhoiise,  G  Indiana  Appellate  Court  Keports,  422  (1892), 
is  a  case  in  which  a  plaintiff'  was  permitted  to  recover  because  he  failed 
to  see  his  mother  before  her  death  in  consequence  of  the  failure  of  the 
defendant  to  deliver  a  telegram.  Womadi  vs.  The  Western  Union  Tele- 
graph Co.,  22  Southwestern  Reporter,  417  (1893),  Court  of  Civil  Appeals 
(^)f  Texas,  is  to  the  same  effect. 

These  and  numerous  other  cases  are  reviewed  ^^Adth  great  ability  by 
Gannt,  P.  J.,  in  Connell  vs.  Western  Union  Telegraph  Co.,  prcAdously  cited. 
He  said:  "We  are  fidly  aware  that  the  plaintiff''s  claim  appeals  strongly 
to  the  sensibilities ;  but  to  adopt  that  view  we  must  either  be  guilty  of 
.adopting  one  ride  of  damages  for  one  class  of  common  can-iers,  and  the 
breach  of  their  contract,  or  we  must  conclude  that  all  of  om*  predecessors 
in  the  great  common-law  coui'ts  were  at  fault,  and  henceforth  repudiate 
not  only  their  utterances  but  our  own  on  this  subject,  and  this  we  have 
no  inclination  to  do.  We  prefer  to  travel  yet  awhile  super  antiqnas  vias. 
If,  in  the  evolution  of  society  and  the  law,  this  innovation  shoidd  be 
deemed  necessary,  the  legislature  can  be  safely  trusted  to  introduce  it, 
with  those  limitations  and  safeguards  which  will  be  absolutely  necessary, 
judging  from  the  variety  of  cases  that  have  sprung  up  since  the  promul- 
gation of  the  Texas  case." 

This  may  be  accepted  as  an  accm-ate  statement  of  the  present  state 
of  the  law  upon  the  subject. 


rEIGNED   DISEASES   OF    THE   MIND  AND   NERVOUS 

SYSTEM. 


PHILIP   COOMBS  KNAPP,  A.M.,  M.D. 


There  are  two  great  motives  wliieli  incite  a  man  to  feign  disease — 
the  desire  to  escape  from  something  unpleasant,  and  the  desire  for  gain. 
The  first  motive  is  most  potent  among  criminals  and  soldiers.  In  the 
former  class  responsibility  for  criminal  acts  may  be  lessened  by  proof 
of  mental  disease,  and  illness  may  alleviate  the  discomforts  of  jDrison 
life,  or  even  obtain  a  pardon.  The  criminal  and  the  loafer  in  our  pub- 
lic institutions  by  simulating  disease  can  often  escaj^e  from  the  hated 
work  and  perhaps  obtain  the  more  agreeable  diet  of  a  hospital.  In  mil- 
itary life  the  illnesses  which  develop  just  before  a  battle  have  caused 
''sogering"  to  become  synonymous  mtli  malingering,  and  in  countries 
where  compulsory  military  service  exists,  numerous  devices  are  reported 
as  practiced  by  those  who  desire  to  escape  conscription.  The  second 
motive  for  feigning  disease  is  the  one  which  will  most  likely  be  met  with 
by  the  physician  in  ordinaiy  practice.  There  are  many  ways  in  modern 
life  in  which  a  man,  although  in  the  exercise  of  due  care,  may  suffer 
personal  injury  by  another's  negligence;  and,  consequent^,  the  dockets 
of  our  courts  are  filled  with  suits  for  damages,  and  railway  coi'porations 
are  compelled  to  pay  large  sums  for  such  purposes,  a  single  corporation 
in  Boston  pajdng  annually  on  an  average  over  $150,000.  Such  acci- 
dents also  lead  to  claims  against  insurance  companies  and  charitable 
associations.  In  other  cases,  the  desire  for  a  pension  may  be  the  cause 
which  leads  the  claimant  to  feign  disease.  Considering,  therefore,  the 
large  number  of  persons  whose  moi'al  sense  is,  to  say  the  least,  defective, 
it  would  not  be  strange  if  many  fraudulent  cases  presented  themselves 
before  the  claim-agents,  and  if  feigning  were  common. 

"With  the  advance  in  our  knowledge  of  disease  and  in  the  methods  of 
clinical  research  it  is  obvious  that  the  difficulty  of  simulation  is  enor- 
mously increased.  Only  those  affections  the  s^-mptoms  of  which  are 
subjective  can  be  successfully  feigned.  The  stethoscope,  the  ophthalmo- 
scope, and  the  microscope  give  us  testimony  which  the  malingerer  can- 
not counterfeit ;  consequently  the  majority  of  surgical  affecti(Uis,  together 
with  most  of  the  diseases  of  the  lungs,  heart,  and  kidue^y,  which  present 
symptoms  clearly  objective,  cannot  be  sinnilated  so  as  to  deceive  the 
trained  physician.  It  is  in  the  domain  of  the  nervous  system  that  the 
majority  of  cases  of  alleged  simulation  occur.     Many  phvsicians  are 

391 


392  -^   SYSTEM  OF  LEGAL  MEDLCINE. 

unfamiliar  with  tlie  rarer  forms  of  nervous  disease  and  with  the  newer 
methods  of  diagnosis,  and  many  of  the  symptoms  are  purely  subjective. 
The  feigning  of  a  broken  leg  is  practically  unheard  of ;  the  feigning  of 
the  various  conditions  classed  as  traumatic  neuroses  is  claimed  to  be  ex- 
tremely common. 

Statistics  as  to  the  frequency  of  feigning  are  somewhat  uncertain,  and 
show  great  variations.  My  personal  belief  is  that  simulation  in  any 
form  is  rare,  and  that  successful  simulation,  if  the  examining  physician 
be  competent,  is  even  rarer.  Out  of  23,903  surgical  cases  admitted  to 
the  Boston  City  Hospital  in  ten  years,  the  diagnosis  of  malingering  was 
made  in  two,  and  in  30,639  medical  cases  the  diagnosis  was  made  in  fif- 
teen. As  might  naturally  be  expected,  mahngering  is  more  frequent  in 
the  office  of  the  admitting  j)hysician  of  the  hospital,  where  a  considerable 
number  of  the  simulators  are  detected  and  turned  away.  In  addition 
to  the  cases  which  were  admitted  to  the  hospital  in  the  ten  years,  there 
were  15,957  rejections,  and  of  these  511  were  refused  admission,  the 
cause  being  assigned  "no  disease  and  mahngering."  Of  these  511  rejec- 
tions, the  admitting  phj^sicians  considered  about  one  fourth  were  cases 
of  malingerers  who  were  anxious  to  get  the  shelter  and  food  of  the 
hospital ;  the  other  three  fourths  were  not  suffering  from  any  disease. 
These  latter  figui-es,  however,  show  merely  the  number  of  rejections,  and 
not  the  number  of  persons,  for  it  has  sometimes  happened  that  a  mahn- 
gerer  has  been  turned  away  eight  or  ten  times  in  the  course  of  a  year. 

In  penal  institutions  malingering  seems  to  be  distinctly  more  com- 
mon, but  its  frequency  seems  to  depend  somewhat  upon  the  strictness- 
of  the  prison  discipline.  A  considerable  number  of  prisoners  will  report 
to  the  physician  at  sick-call  in  the  morning  for  the  sake  of  escaping 
from  work  for  a  time,  or  in  the  hope  of  being  admitted  to  the  prison 
hospital ;  but  such  cases  are  usuall}^  readily  detected,  and  they  seldom 
attempt  such  a  proceeding  except  upon  a  new  physician  whom  they  think 
is  inexperienced.  In  my  own  ex]3erieuce  and  in  that  of  my  colleagues 
at  the  Suffolk  County  House  of  Correction  in  Boston,  there  were  many 
cases  who,  we  thought,  came  to  sick-call  when  there  Avas  no  real  disease ; 
but  the  physicians  who  have  been  in  charge  at  the  House  of  Correction 
in  recent  years  agree  that  there  have  been  very  few  eases  of  dehberate 
and  persistent  simulation  of  any  form  of  disease  or  of  insanity.  Dr.  W. 
B.  Bancroft,  the  present  physician,  has  informed  me  that,  in  his  opinion, 
simulation  was  distinctly  rare ;  that  in  five  years  fifty  x)risoners  have  been 
committed  to  insane  asylums,  and  that  there  were  only  three  cases  where 
insanity  was  dehberately  feigned.  Dr.  G.  F.  Jelly,  the  examiner  in  lunacy 
for  the  public  institutions,  coincides  in  this  opinion,  and  adds  that  cer- 
tain cases,  which  were  believed  to  have  feigned  insanity,  gave  cAddence 
of  genuine  insanity  after  admission  to  an  asylum.  At  the  Massachusetts 
Reformatory  Prison  at  Concord  Dr.  Gr.  E.  Titcomb  writes  that  there  is 
little  simulation ;  however,  the  men  have  a  powerful  motive  for  refrain- 
ing from  deceit,  because  the  length  of  their  sentence  is  determined  by 
good  behavior.  Where  prison  discipline  is  relaxed,  however,  mahnger- 
ing becomes  much  more  frequent.  Dr.  C.  D.  Sawin  wi'ites  me  that  at 
tlie  Massachusetts  State-prison  at  Charlestown,  where  the  discipline  has 
been  very  lax,  feigning  has  been  extremely  common,  but  usually  it  has 
been  readily  detected. 

Statistics  from  the  pension  offices  as  to  simulation  are  not  easily  to 


FEIGNED   DISEASES   OF  THE  2IIXD  AND   MiRIOUS  SYSTEM.     393 

be  obtained  in  sufficient  numbers  to  give  a  definite  opinion,  but  the  im- 
pression of  severtil  of  the  examiners  seems  to  be  that  deliberate,  conscious 
simuhition  is  i"ire. 

The  (juestion  as  to  the  frequency  of  simulation  has  been  most  dis- 
cussed with  refei-ence  to  the  claims  for  danuxg-es  for  personal  injuries, 
and  here  opinions  vary  very  greatly.  Hodges  {Boston  Med.  and  Surr/. 
Journal,  April,  1881)  believed  that  out  of  21  cases  he  had  seen,  10  were 
fraudulent  and  6  were  doubtful.  Rigler  {Rerne  Medicale,  January,  1879, 
Ueber  die  Folgen  der  Verletzungen  auf  Elsenhalinen)  out  of  28  cases  thought 
7  were  fraudulent  and  13  doubtful.  Page  {Tiijnrie.<i  of  the  ISpuie  and  )Sj>i- 
nal  Cord)  in  234  cases  considered  simulation  or  gross  exaggeration  to  be 
veiy  common.  To  these  figures,  however,  the  objection  may  at  once  be 
raised  that  they  are  the  opinions  of  surgeons  accustomed  to  deal  with 
ol)jective  symptoms,  and  unfamiliar  ^\dth  the  subtler  and  more  obscure 
phenomena  found  in  nervous  diseases.  It  is  obvious  that  only  a  man 
with  long  experience  in  the  observation  of  patients  with  mental  and  nerv- 
ous diseases  can  judge  correctly  of  the  reality  of  nervous  sjmiptoms.  It 
is  only  within  a  very  few  years  that  neurologists  have  l:)rouglit  forward 
statistics  sho■\^dng  the  frequency  of  simulation.  In  1890  J.  H.  Hoffmann 
{Berlin.  l-lin.Wochenschr.,  July,  1890)  started  a  discussion  upon  this  sub- 
ject, Avhich  was  carried  on  at  the  Berlin  International  Medical  Congress 
in  the  same  jea,Y  by  Schultze  {Sammlung  Min.  Vorfrdge,  No.  14,  1890), 
Seeligmiiller  {DeutseJie  med.  Wochenschr.,  October,  1890),  Mendel,  and 
others  {Verliand.  des  X.  internat.  med.  Congress,  B.  iv.,  Ab.  ix.). 

The  writers  mentioned  claimed  that  in  the  so-called  traumatic  neu- 
roses simulation  was  extremely  common,  existing  in  from  one  fourth  to 
one  third  of  all  the  cases.  The  cases  which  they  published  in  support 
of  their  opinions  are  not,  however,  absolutely  conclusive ;  the  variable 
character  of  symptoms  often  observed  in  hysteria  and  neurasthenia,  and 
some  of  the  subtler  peculiarities  in  those  symptoms,  seem  to  have  been 
overlooked,  and  in  more  than  one  instance  the  destructive  criticism  of 
Dubois  {Corr.-Bl.  f.  scliweiz.  Aerzte,  September,  1893),  Mobius  {Miincli. 
med.  Wochenschr.,  September,  1891),  Oppeuheim  ( ^Yeife)^e  Mitfheiluugen  in 
Bezug  auf  die  traum.  Neiirosen),  and  others,  has  shown  that  the  accusation 
of  simulation  was  not  substantiated.  Indeed,  in  a  later  communication, 
Schultze  {Deutsche  Zeitschr.  f.  Nervenheilh.,  vol.  i.,  p.  445)  found  only  ten 
percent,  of  simulation  instead  of  thirty,  as  in  his  previous  series. 

It  is  clear  that  simulation  ought  frequently  to  be  seen  in  the  claim- 
agent's  room  more  than  in  the  office  of  the  neurologist,  and  claim-agents, 
corporation  lawyers,  and  railway  surgeons  are  fond  of  saying  that  the  vast 
majority  of  cases  are  frauds.  The  more  pronounced  cases  of  simulation 
are  recognized  at  once,  and  only  the  doubtful  cases  run  the  gauntlet 
successfully  and  are  subjected  to  the  expert  judgment  of  the  neurolo- 
gist. Even  in  the  whole  nniss  of  cases  that  come  to  the  claim-agent's 
office,  however,  the  amount  of  deliberate  simulation  seems  to  be  small. 
Dr.  M.  D.  Field  {Traits.  Am.  Keur.  Assoc,  1893;  Joiirn.  Xerr.  and  Mrut. 
J)is.,  March,  1894),  the  examining  surgeon  of  the  Manhattan  Elevated 
Eailway,  has  stated  that  deliberate  sinnilation  is  seen  only  in  a  very 
small  percentage  of  the  eases,  and  that  in  such  cases  it  is  so  manifest 
and  the  s3'mptoms  are  so  grossly  exaggerated  as  to  be  at  once  recognized 
by  a  trained  observer.  Other  examining  physicians  have  expressed  to 
me  similar  opinions.     My  own  personal  experience  coincides  fully  ^^'ith 


394  ^   SYSTEM  OF  LEGAL  MEDICINE. 

tliese  views.  In  less  tlian  four  percent,  of  the  cases  that  have  come 
under  my  own  observation  was  simulation  at  all  probable,  and  I  have 
succeeded  in  demonstrating-  the  genuineness  of  the  symptoms  in  some 
cases  where  simulation  was  claimed  by  good  observers,  and  I  have  also 
known  some  suspected  cases  to  terminate  fatally.  Exaggeration  of 
symptoms  is  more  common,  but  it  must  be  remembered  that  exaggera- 
tion is  a  common  feature  in  all  sorts  of  nervous  diseases,  where  intro- 
spectiveness,  hypochondriasis,  and  fear  lead  the  patient  to  make  much 
of  minor  ailments. 

The  possibility  of  the  successful  simulation  of  the  various  forms  of 
nervous  disease  is  not  great,  provided  the  investigator  be  familiar  mth 
the  clinical  manifestations.  The  sijnulator's  task  is  not  easy.  He  must 
Ibe  as  familiar  with  all  the  symptoms  of  the  feigned  disease  as  the  phy- 
isician  is,  he  must  be  prepared  for  aU  the  forms  and  variations  of  tests 
employed  in  a  clinical  examination,  and  he  must  be  constantly  on  his 
guard  lest  he  betray  himself  by  some  unguarded  admission.  It  is  clear 
that  such  knowledge  and  such  skiU  are  beyond  the  g:rasp  of  the  average 
patient.  Many  of  the  minor  symptoms  of  nervous  clisease  and  the  more 
€xact  and  elaborate  methods  employed  in  their  diagnosis  are  unknown 
even  to  the  average  physician,  and  the  patient  cannot  learn  of  some  of 
them  unless  he  is  able  to  read  a  foreign  language.  Granting  that  he 
could  acquire  this  knowledge,  or  that  he  could  find  a  physician  suffi- 
ciently expert  to  coach  him,  another  diificulty  stands  in  the  way:  he 
must  simulate  all  these  symptoms  accurately  before  a  physician  at  least 
as  weU  acquainted  with  them  as  his  coach,  familiar  with  aU  the  symptoms 
of  the  disease  feigned,  and  ready  at  any  mistake  to  catch  hun  off  his 
guard.  Recent  psychological  investigations,  however,  have  shown  that 
a  man  can  keep  his  mind  fixed  upon  any  special  topic  only  for  a  short 
time.  Hence  most  persons,  even  if  they  know  the  particular  movement 
which  constitutes  the  "trick"  of  a  sleight-of-hand  performance,  will  fail 
to  note  it  because  the  performer  chooses  the  one  moment  to  make  that 
movement  when  their  attention  is  distracted.  The  simiQator  must  be 
prepared  to  feign  a  dozen  symptoms  at  the  same  time,  so  that  his  task 
becomes  much  more  formidable,  and  a  successful  examiner  can  readily 
take  him  off  his  guard  by  the  application  of  some  unexpected  test.  This 
lias  been  clearly  shown  by  Pitres  {Lemons  cVmiques  sur  Vliysterie,  vol.  i., 
p,  79),  who  had  a  remarkably  good  opportunity  to  prove  it.  A  man  had 
for  several  years  taken  the  part  of  the  ana?sthetic  man  in  a  show,  en- 
during pricks,  cuts,  etc.,  without  the  slightest  manifestation  of  pain.  In 
order  to  obtain  the  shelter  of  hospital  life  this  man  feigned  a  disease, 
one  symptom  of  Avhich  was  anesthesia ;  but  when  he  was  subjected  to 
the  unexpected  application  of  painful  stimuli  Pitres  proved  at  once  that 
the  anaesthesia  was  feigned. 

One  of  the  striking  characteristics  of  the  average  simulator  is  that  his 
^symptoms  are  usually  pronounced,  and  are  always  made  prominent  in 
the  clinical  picture.  There  is  paralysis,  not  weakness ;  antesthesia,  not 
diminished  sensibility ;  violent  pain,  not  aching.  He  calls  attention  to 
iiis  symptoms ;  they  do  not  have  to  be  sought  for  by  special  tests  in  a 
clinical  examination.  Such  symptoms  as  a  moderate  contraction  of  the 
-visual  field,  a  diminished  sensibility  to  pain  or  temperature,  with  normal 
isensibility  to  touch,  or  the  quibblings  or  questionings  of  insanity  of 
Joubt,  have  nothing  to  do  with  his  complaints.     Tlie  exaggeration  of 


FEiaXED   DISEASES   OF   THE  MIX  I)  AM)   S  EI!  10  US  SYSTEM.     ^95 

syniptoins,  the  manner  of  thrusting  them  before  the  examiner,  the  ab- 
sence of  any  shading-  or  qnalification,  the  total  absence  of  objective  phe- 
nomena, the  detection  of  false  statements  -with  i-egard  to  certain  symp- 
toms of  a  partly  objective  character,  and  the  like,  render  the  detection  of 
fi-and  easy. 

It  nnist  be  borne  in  mind,  however,  that  contradictory  statements 
and  even  conflicting  data  from  examinations  are  l)y  no  means  absolute 
proof  of  simulation.  A  very  limited  acquaintance  with  patients  suffer- 
ing from  actual  disease  will  prove  how  contradictory  their  statements 
sometimes  nuiy  be,  and,  in  nervous  troubles  especiall}',  how  their  condi- 
tion may  vary  from  one  hour  to  the  next ;  what  an  influence  expectant 
attention  has  upon  their  symptoms  5  and  how  suggestible  they  may  be 
to  the  slig]]test  influence.  Certain  conditions,  too,  may  seem  absolutely 
contradictory,  and  may,  to  the  inexperienced,  seem  absolute  proof  of  the 
unreality  of  all  the  patient's  complaints.  Thus,  tenderness  so  extreme 
that  the  slightest  touch  cannot  be  borne  may  be  associated  ^vith  com- 
parative insensibility  to  deep  pressure;  hysterical  amblyopia  may  be 
shown  to  be  really  psychical,  and  to  exist  only  on  monocular  vision ; 
complete  inability  to  stand  or  walk,  as  in  astasia-abasia,  may  be  associ- 
ated with  normal  strength  and  power  of  coordination  in  the  legs,  and 
the  like  ;  so  that,  without  knowledge  of  such  conditions,  the  diagnosis  of 
simulation  is  often  incorrectly  made. 

In  the  detection  of  attempts  to  feign  disease  certain  general  rules  are 
to  be  borne  in  mind.  Whenever  it  is  possible,  confirmatory  evidence 
should  be  sought  from  disinterested  persons  in  regard  to  the  patient's 
condition.  Then  the  histoiy  should  be  obtained  from  the  patient  him- 
self. Careful  inquiry  should  be  made  in  regard  to  all  the  bodily  func- 
tions, and  detailed  inquiries  in  regard  to  all  his  complaints.  The  simu- 
lator usually  proclaims  all  his  sulferings  loudly,  but  the  genuine  sufferer 
may  often  require  close  cross-examination  to  elicit  the  Avhole  story.  It 
is  well  to  i-eturn  after  an  interval  to  certain  symptoms  in  order  to  see 
whether  the  patient's  story  is  consistent  or  not,  and  to  ask  if  he  has  ever 
had  certain  symptoms,  either  impossible  in  themselves  or  inconsistent 
with  the  type  of  disease  he  presents.  It  must  be  remembered  that  many 
people  are  incapable  of  telling  a  connected  story  or  of  giving  an  accurate 
account  of  real  sufferings,  that  many  affections  show  pronounced  varia- 
tions, and  that  sometimes  the  claim  that  the  symptoms  always  remain 
the  same,  or  of  the  same  severity,  may  of  itself  be  suspicions.  During 
the  process  of  taking  the  history,  the  patient  should  be  quietly  and  un- 
obtrusively watched,  and  it  may  be  that  he  will  be  detected  in  performing 
some  act  which  he  has  just  announced  himself  incapable  of  performing. 

The  taking  of  the  case  history  sliould  be  followed  by  a  thorough  and 
complete  physical  examination,  paying  especial  attention  to  the  motor 
functions,  sensation  (including  sensibility  to  pain  and  temperature  as 
well  as  to  touch),  the  si)ecial  senses  (always  including  exnmination  with 
the  ophthalmoscope  and  perimeter),  nutrition,  the  electrical  reactions,  the 
reflexes,  and  the  condition  of  the  internal  organs.  It  is  safe  to  say  that 
if  there  be  any  real  disease  of  the  nervous  system  such  a  complete  ex- 
amination A^dll  reveal  some  symptoms  which  it  is  either  impossible  or 
extremely  improbable  for  the  patient  to  fi'ign.  Among  the  symptoms 
which  cannot  be  feigned  are  optic  neiiritis  and  atrophy,  Argyll-Robertson 
pupils,  nystagmus,  muscular  atrophy,  reactions  of  degeneration,  loss  of 


396  -4   SYSTE2I  OF  LEGAL  MEDICINE. 

knee-jerk,  ankle  clonus,  and  a  difference  in  the  activity  of  the  skin  and 
tendon  reflexes  on  the  two  sides.  After  this  the  physician  "otII  probably 
be  in  a  position  to  give  a  defiuite  opinion.  Sometimes  relocated  exami- 
nations will  be  necessaiy,  and  in  rare  cases  it  may  be  necessary  to  apply 
the  crucial  test  of  protracted  observation  in  a  hospital.  Seehgmiiller 
{Art.  cif.;  VerliamU.  des  X.  Intermit.  Med.  Conyress,  B.  iv.,  Ab.  ix.)  has  urged 
this,  and  thinks  it  ad\dsable  to  estabhsh  observation  hosjDitals  where 
patients  who  claim  damages  on  account  of  traumatic  nervous  affections 
may  be  sent.  In  very  few  cases,  however,  would  such  hospitals  be  re- 
quii'ed. 

Until  the  physician  be  absolutely  con\TJiced,  after  a  thorough  exami- 
nation, that  the  patient  is  feigning,  it  is  important  not  to  treat  him  as 
a  mahngerer.  Such  a  eoui-se  will  directly  antagonize  the  patient  and- 
his  friends,  and  the  cases  of  deliberate  feigning  are  too  few  to  justify  it. 
The  suggestion  made  long  ago  by  Casper  {Handh.  d.  GericJitl.  Med.,  B.  i., 
Ab.  V.)  that  the  physician  should  make  unexpected  visits  to  the  patient 
to  catch  him  off'  his  guard  would  naturally  arouse  suspicion,  and  thus 
do  more  harm  than  good,  and  this,  and  similar  proceedings,  will  seldom 
be  found  necessary. 

With  a  thorough  knowledge  of  modern  methods  of  clinical  research, 
the  old  brutal  methods  of  ignorance  must  be  abandoned.  Flagellations, 
douches,  and  the  cautery  may  injure  one  who  is  really  suffering,  and  they 
give  no  help  to  the  scientific  obserN^er.  Even  the  so-called  crucial  ex- 
periment of  etherization  will  rarely  be  necessary.  It  is  of  legitimate  use 
in  the  diagnosis  of  certain  affections,  as  is  well  known ;  but  it  is  not 
whoUy  devoid  of  danger,  and  it  shoidd  be  employed  in  suspected  simula- 
tion only  in  cases  where  we  might  legitimate^  employ  it  in  ordinary 
diagnosis. 

Many  writers  point  out  the  danger  to  the  malingerer  of  feigniug  dis- 
ease. B}^  persistently  feigning  certain  s^anptoms  there  is  danger  that  a 
morbid  habit  may  be  established,  and  the  feigned  disease  may  become 
real.  This  is  held  to  be  especially  true  of  attempts  to  feign  insanity.  I 
have  seen  one  case  where,  in  order  to  obtain  a  jjardon,  a  prisoner  at  fii'st 
deliberately  induced  vomiting,  but  finally  the  vomiting  got  beyond  his 
control,  and  although  he  became  alarmed  at  his  condition  and  wanted 
to  stop,  he  was  for  some  time  unable  to  control  the  vomiting.  In  manj^ 
cases,  however,  allowance  must  be  made  for  the  mistakes  of  the  physi- 
cian, who  regards  the  early  symj^toms  of  mental  or  nervous  disease  as 
feigned,  onlj-  to  find  out  later  that  there  is  really  trouble. 

I  have  spoken  thus  far  of  the  deliberate  feigning  of  disease.  There 
are,  however,  foiu"  conditions  to  be  borne  in  mind  by  the  ph^'sician  in 
examining  the  ordinary  cases :  first,  eases  where  no  disease  exists  and 
all  the  sjTiiptoms  are  deliberately  feigned ;  second,  where  there  is  some 
disease,  but  the  symptoms  are  greatly  exaggerated  and  additional  symp- 
toms perhaps  feigned ;  thu-d,  where  certain  morliid  conditions  are  delib- 
eratel}"  produced  b}'  the  patient,  such  as  conjunctiWtis,  skin  affections,, 
and  the  like  :  fourth,  where  the  symptoms,  although  genuine,  are  not  due 
to  the  alleged  cause  but  have  existed  long  before.  Although  deliberate 
simulation  is,  in  my  oi)iiiiou,  rare,  and  is  usually  easily  to  be  detected,  it 
is  a  harder  matter  to  determine,  when  there  is  genuine  disease,  how  far 
the  complaints  are  exaggerated.  In  many  cases  exaggeration  is  in  itself 
a  sjTuptom  of  nervous  disturbance;    iutrospectiveness,  hypochondria. 


FEIGNED  DISEASES   OF  THE  MIM)  AND  NERl'OUS  SYSTEM.     Ijijj 

and  exafi:^eratioii  are  cLaractoristics  of  tlie  Dicntal  foiidition  of  many 
nervous  patients.  To  appreeiate  these  conditions  justly  i-ecpiires  long 
familiiirity  with  nervous  patients  and  nervous  affections;  and,  as  a  rule, 
the  physician  and  the  fi-ieuds  are  too  apt  to  undervalue  their  coni})laints. 
For  the  detection  of  exa^"<j;'eratioii  no  delinite  rules  can  be  j;iveii ;  the 
physician  nuist  be  ^iiided  by  his  knowledge  of  nervous  disease  in  g(;neral, 
by  his  pcn-sonal  estimate  of  the  individual  case,  and  by  his  general  knowl- 
edge of  hunnm  nature.  He  nuiy  be  aided  in  some  cases  by  the  lack  of 
correspondence  betw^een  the  complaints  and  the  symptoms  revealed  by 
an  examination,  and  by  the  statements  of  the  patient's  friends  and  ac- 
quaintances, especially  l)y  disinterested  observers.  The  chances  of  ei-ror 
in  damage  suits  from  the  statements  of  interested  friends  are  too  obvious 
to  need  jnentio]i.  It  is  well  to  bear  in  niiud  a  source  of  error  on  the 
other  side  in  the  frecpient  tendency  among  tlui  laity  to  make  light  of  all 
nervous  troubles  and  to  regard  thein  as  imaginary. 

In  cases  of  the  third  class,  where  morbid  conditions  are  deliberately 
produced  by  the  act  of  the  patient,  we  are  seldom  in  a  position  to  detect 
this  by  the  symptoms  alone,  and  in  such  cases  we  must  be  gidded  by  the 
evidence  brought  forward  to  show  such  facts. 

In  cases  of  the  fourth  class  also  the  physician  is  rarely  in  a  position 
to  testify  as  to  the  exact  relation  between  the  alleged  cause  and  the 
symptoms.  The  symptoms  may  be  wholly  due  to  pi-eexisting  disease, 
or  the  accident  may  have  aggravated  some  of  the  symptoms  of  such  a 
disease.  In  some  cases  indications  of  previous  trouble  may  be  elicited 
on  close  inquiry;  the  patient  may  admit,  for  instance,  the  existence  of 
rheumatic  pains  for  years  before  an  accident,  and  these  pains  may  have 
been  the  earlj^  symptoms  of  a  tabes  which  has  been  referred  to  the  acci- 
dent. Such  questions  are  often  not  a  matter  of  expert  opinion  ])ut  a 
matter  to  bo  determined  l)y  ordinary  evideiu'e,  and  the  only  position 
which  the  physician  can  take  is  to  state  that  the  existing  condition  may 
well  have  been  due  to  such  an  accident  as  the  patient  is  said  to  have  suf- 
fered. Whether  the  disease  existed  before  the  accident,  or  whether  the 
patient  ever  exj)erienced  an  accident,  are  alike  questions  of  evidence  which 
the  jury  must  determine. 

Having  thus  discussed  the  general  conditions  relative  to  the  feigning 
of  disease,  it  remains  to  consider  the  possibilities  of  feigning  the  various 
symptoms  of  nervous  disease,  since  the  consideration  of  foiigning  in  spe- 
cial cases  can  be  more  succinctly  aiul  (dearly  treated  in  this  way  than  by 
the  attempt  to  discuss  the  simulation  of  individual  types  of  disease.  The 
feigning  of  insanity,  however,  can  better  be  considered  under  a  sei^arate 
heading. 

MOTOR   SY1MPT0JI8. 

Paralysis. — Paralysis,  beiiig  one  of  the  most  striking  symptoms  of 
motor  disturbance,  is,  next  to  convulsions,  the  symptom  most  likely  to  be 
feigned.  Certain  associated  syniptojiis,  hoAvever,  Avlien  ])resent,  render  it 
exceedingly  improbable  that  the  i)aralysis  is  feigned.  Thus,  if  })aralysis 
be  associated  with  nniscular  atro])hy,  esi)ecially  with  degenerative  atro- 
phy, with  contracture,  vasomotor  disturbances,  or  changes  in  the  re-" 
flexes  (symptoms  which  of  themselves  cannot  be  feigned),  the  paralysis 
is  also,  in  all  probability,  genuine.  If  there  be  anaesthesia,  which,  as 
will  be  shown  later,  is  hard  to  feign,  the  probabihty  that  the  i)aralysis  is 


398  ^    SYSTEM  OF  LEGAL  MEDICINE. 

feigned  becomes  distinctly  small.  If  the  paralysis  be  limited  to  tbe  dis- 
tribution of  a  peripheral  nerve  or  a  spinal  segment,  it  is  highly  improb- 
able that  the  patient  has  knowledge  siifficient  to  make  the  attempt  to 
simulate  such  a  condition,  and  it  is  often  impossible  for  hun  to  have  such 
control  of  the  muscles  as  to  succeed  in  Ms  attempt.  Furthermore,  the 
voluntary  control  over  some  of  the  muscles,  such  as  the  ocular  muscles, 
the  upper  facial  muscles,  and  the  like,  is  not  sufficient  in  most  cases  for 
the  patient  to  feign  paratyses  of  them.  Most  paralyses  of  long  standing 
show  simple  atrophy  of  the  muscles  from  disuse — the  limb  is  smaller, 
and  the  muscles  feel  softer  and  flabbier.  It  is  therefore  evident  that  the 
question  of  simulation  is  hkely  to  arise  onty  when  there  is  a  recent  flac- 
cid paralysis,  without  ansesthesia  and  mthout  degenerative  reactions  and 
atroph}".  In  such  cases  it  may  be  possible  to  detect  the  fraud  by  notic- 
ing movements  in  the  limb  claimed  to  be  paral}'zed,  when  the  patient  is 
off  his  guard,  or  is  attempting  to  do  some  ordinary  act  such  as  taking 
off  his  clothes ;  by  finding  that  when  the  patient  stoops  the  limb  is  held 
rigidly  to  the  side  and  does  not  follow  the  action  of  gravity ;  that  passive 
movements  are  unconsciously  resisted,  and  the  like.  In  feigned  hemi- 
plegia the  characteristic  droop  of  the  shoulder,  the  circumduction  and 
dragging  of  the  toe  of  the  paralyzed  leg,  the  greater  degree  of  paralysis 
in  the  arm  and  in  the  distal  joints,  and  like  spnptoms,  may  be  absent. 
The  shoe  may  not  show  the  wear  uj)on  the  inner  and  anterior  portion 
<)t  the  sole  that  it  would  if  the  foot  were  persistently  di'agged.  If  the 
paralyzed  hmb  be  held  up  for  a  time  and  the  support  suddenly  removed, 
it  may  not  fall  immediately.  In  hysterical  paralysis,  however,  many  of 
these  characteristics  may  be  absent.  Thus,  in  hysterical  hemiplegia  there 
is  not  the  circumduction  of  the  leg,  the  j^roximal  joints  may  be  as  much 
jjaralyzed  as  the  distal,  and  the  influence  of  suggestion  may  keep  the 
paralyzed  limb  extended  when  the  support  has  been  taken  away.  In 
such  cases  the  detection  of  hysterical  stigmata  may  enable  the  physician 
to  make  an  acciu-ate  diagnosis  and  to  determine  that  the  paralysis  is  gen- 
nine.  With  a  flaccid  paralysis,  without  any  stigmata,  where  the  patient 
makes  none  of  the  eiTors  just  mentioned,  it  may  be  necessary  to  subject 
him  to  a  more  protracted  observation.  In  such  eases  the  application  of 
powerful  faradic  currents  may,  on  account  of  the  pain  which  they  cause, 
lead  the  patient  to  make  voluntary  movements ;  and  during  the  period 
of  excitement  at  the  fii'st  administration  of  ether,  on  recovery  from  ether- 
ization, on  waking  from  sleep,  or  when  under  the  influence  of  alcohol,  the 
alleged  paralyzed  limb  will  often  be  moved. 

Paralyses  of  the  sphincters,  which  often  occui'  especially  in  spinal 
paralyses,  can  readily  be  detected.  If  the  patient  has  been  subjected  to 
a  long  examination,  without  an  opportunity  of  passing  water,  and  at  the 
end  of  that  time  the  clothing  be  still  dry,  his  complaints  of  incontinence 
lack  credibility.  In  true  incontinence  the  characteristic  odor  and  the 
reddened,  irritated  condition  of  the  skin  ^\dll  indicate  that  the  cloth- 
ing is  constantly  wet.  Wichmann  [Der  Werth  der  Sifnipfoine  der  sogen. 
tranm.  Xeurose,  p.  15)  has  suggested  that  in  alleged  incontinence  the 
meatus  be  carefully  dried  with  absorl)ent  cotton  ;  if,  after  that,  the  urine 
be  found  oozing  from  it,  it  is  proof  that  the  incontinence  is  genuine, 
since  the  urine  cannot  be  voided  in  this  way  voluntarily.  Paralysis  of 
the  sphincter  ani  can  be  readily  recognized  from  the  patulous  condition 
of  the  anus  on  inserting  the  finger. 


FEIGNED  DISEASES   OF  THE  MIND  AND  NERVOUS  SYSTEM.     399 

In  conditions  of  paresis  the  detection  of  simulation  is  not  so  easy. 
Oppenlieini  {Die  frauniatische  Nenrosen,  p.  149,  2  Anjl.)  has  stated  that  in 
some  cases  of  traumatic  nervous  affection  the  patient  makes  apparently 
great  effort  and  calls  many  muscles  into  play,  without  accomijlishing' 
any  great  resvdt,  the  memory  of  the  muscular  effort  required  being  lost. 
Such  a  condition  may  give  rise  unjustl}^  to  the  suspicion  of  simulation. 
In  most  cas(^s  we  must  be  aided  l)y  other  associated  symptoms.  Wich- 
mann  [op.  eif.,  p.  5G)  has  suggested  a  metljod  of  testing  the  muscular 
strengtii  l)y  the  dynamometer  in  alleged  paretic  conditions,  the  value  of 
which  I  have  been  able  to  corroborate  by  personal  experiment.  The  pa- 
tient is  l)lindfolded  and  told  to  squeeze  the  d3'namometer  to  the  extent 
of  his  strength.  If  he  does  so,  the  index  will  reach  very  nearly  the  same 
point  each  time,  although  after  several  trials  the  strengtii  begins  to  dimin- 
ish. If  the  patient  does  not  exert  his  full  strength  lie  will  not  squeeze 
to  the  same  point  each  time,  but  there  will  be  quite  distinct  variations. 
This  test  may  be  applied  to  the  muscles  of  the  leg  by  means  of  the  apjia- 
ratus  recently  described  by  Krauss  {Trans.  Am.  KeMr.  Assoc,  1893). 

Convulsions. — Epilepsy,  the  chief  convulsive  disorder,  is  the  form 
of  nervous  disease  most  frequently  feigned.  The  epileptic  seizure  is  so 
striking,  and  the  disease  itself  is  so  common  and  is  so  weU  recognized  as 
a  grave  disorder  which  may  lead  to  serious  mental  disease,  that  malin- 
gerers are  especially  apt  to  feign  it.  It  is  one  of  the  commoner  forms 
of  nervous  disease  feigned  by  criminals,  either  in  the  hope  of  escaping 
work,  or  of  being  sent  to  a  hosj)ital  or  an  asylum.  There  is  also  a  special 
class  of  criminals  who  feign  epileptic  attacks  (''chuck  a  dummy")  in 
pul)lic  places  to  attract  a  crowd,  the  performer  obtaining  alms  from  the 
benevolent  on  account  of  his  malady,  while  his  accomplices  pick  the 
pockets  of  the  by-standers. 

It  is  a  point  in  favor  of  the  genuineness  of  the  disorder  if  it  can  be 
proven  that  the  patient  has  had  such  attacks  since  childliood.  Attacks 
coming  on  in  adult  life  where  there  is  a  powerful  motive  for  simulation 
may  be  regarded  with  suspicion.  The  average  simulator  has  his  attacks 
only  when  he  thinks  he  is  observed;  he  seldom  falls  so  as  to  hurt  him- 
self ;  he  is  not  likely  to  pass  urine  or  fa?ces  in  his  clothing ;  the  move- 
ments ai'e  more  exaggerated  than  are  usual  in  epileps}^ ;  they  may  not  be 
at  all  like  the  epileptic  movements,  and  they  are  often  limited  to  the  ex- 
tremities ;  the  tongue  is  less  apt  to  be  bitten ;  the  simulator  seldom  speaks 
of  the  aura,  and  he  may  omit  the  characteristic  cry.  Other  s^inptoms 
are  more  difficult  to  feign.  During  a  genuine  attack  the  patient  is  un- 
conscious and  anaesthetic,  the  pupils  are  often  dilated  and  almost  always 
immobile,  and  the  conjunctivji?  are  aiuestlietic  ;  the  epileptic  is  often  pale 
at  the  onset  of  the  attack,  and  l)ecomes  cyanotic  if  the  convulsion  be 
severe  ;  after  a  severe  convulsion  there  is  profound  sopor.  Opisthotonos 
and  the  short  contractions  of  the  spinal  muscles  can  be  feigned  only 
with  great  difficulty.  Heller  {Si))ifilafiour)i  toid  Hire  BeJunnlIiinf/,  p.  35) 
lias  suggested  that  during  a  suspicious  attack  firm  pressure  be  made  l>y 
the  hand  on  some  group  of  muscles,  such  as  the  thigh  muscles ;  after  a 
time  these  muscles  will  relax ;  if  then  an  attempt  be  made  to  flex  the 
limb  the  simulator  will  contract  the  muscles  again.  If  the  clenched  hand 
be  opened  during  a  genuine  attack  it  will  not  be  closed  again — a  simu- 
lator is  apt  to  close  it.  After  a  severe  attack,  as  was  first  pc^inted  out 
by  Hughlings  Jackson  {Medical  Times  and  Gazette,  February,  1881),  and 


400  A  SYSTJEM  OF  LEGAL  MEDICINE. 

as  I  have  myself  seen  in  several  cases,  there  may  be  ankle  clonns  or  loss 
of  knee-jerk,  s^nnptoms  wkicli  cannot  be  feigned.  After  a  succession 
of  fits  the  temperatnre  rises,  in  exti'eme  cases  reaching  40°  C.  or  more 
(104°  or  105°  F.).  The  confii-med  epileptic  has  a  characteristic  facial  ex- 
23ression,  f amihar  to  all  who  have  seen  many  cases ;  his  face  is  often  dis- 
figm-ed  by  the  bromide-acne,  and  the  tongue,  head,  and  body  often  bear 
scars  from  the  injuries  received  in  the  attacks. 

The  simulator  of  epilepsy  can  be  unmasked  in  various  ways.  "West- 
phal  [Berlin.  Min.WochenscJir.,  No.  40, 1878)  and  Winkler  (Heller,  op.  cit., 
p.  33)  have  both  detected  cases  by  sajdng  in  the  patient's  presence  that 
certain  movements,  such  as  no  epileptic  performs  (for  instance,  extending 
the  arm  and  spreading  the  fingers),  ought  to  be  performed  in  the  attack, 
and  the  simulator  in  his  next  attack  performed  them.  Tamassia  [Rivista 
sper.  di  freniafria,  vol.  x^dii.,  p.  140)  reports  a  case  of  a  woman  who  feig'ned 
spnptoms  of  insanity  and  epilepsy.  He  found  that  she  remembered 
what  happened  dui'ing  her  attacks,  and,  after  she  had  overheard  his  in- 
quiiies  as  to  whether  she  had  certain  symptoms  in  her  attacks,  she  pro- 
truded her  tongue  to  the  left  dimng  an  attack,  vomited,  contracted  her 
fingers  in  a  curious  way,  cried  out  in  a  way  unlike  the  epileptic  cry,  kept 
the  left  arm  rigid  and  the  right  arm  flaccid,  protruded  the  tongue  when 
asked  to  do  so,  and  finally  had  an  attack  when  the  cer^dcal  vertebras  were 
pressed  upon — none  of  which  sjmiptoms  had  she  shown  before  they  were 
spoken  of  in  her  iDresence.  A  prisoner  at  the  Massachusetts  State-prison 
-ceased  his  con^o^dsion  when  it  was  proposed  to  give  him  ether,  of  which 
he  stood  in  great  di^ead. 

Given  a  motive  for  feigning,  it  is  ground  for  suspicion  when  a  patient 
has  a  fit  in  the  physician's  presence.  Out  of  ninety  cases  of  epilepsy  in 
patients  who  were  able  to  come  to  see  me  I  recall  but  three  who  have 
ever  had  fits  during  such  a  visit,  and  it  is  often  difiicult  to  get  the  oppor- 
tunity of  obser^dng  a  fit  from  its  beginning  when  the  patient  is  in  tlie 
w^ards  of  a  hospital.  Partly  from  the  occurrence  of  a  fit  on  his  first  ^dsit 
and  partly  because  the  patient  did  not  close  the  hand  over  the  thumb, 
Macdonald  {Boston  Med.  and  Sxrg.  Jour.,  December,  1S80)  was  able  to  un- 
mask the  "  dummy-chucker"  Clegg,  who  had  baffled  many  prison  officials 
and  jjh^^sicians,  and  had  several  times  escaped  punishment  or  prison 
duty  on  account  of  his  supposed  epilepsy.  This  case  was  so  remarkable 
that  it  merits  a  brief  notice.  Clegg,  by  much  study  and  observation,  had 
learned  to  imitate  fits  very  accurately.  In  an  attack  he  made  no  mani- 
festation of  feeling  when  pins  were  thrust  under  his  nails  or  when  the 
cornea  was  toiit^hed  ;  he  turned  livid,  bloodj''  frothy  saliva  came  from  the 
mouth,  his  head  was  turned  back,  and  the  trunk  was  twisted  in  an  attack. 
In  one  attack  he  had  clonic  spasm  of  the  muscles  of  the  neck  so  that  the 
head  was  beaten  against  the  floor  mth  force  enough  to  abrade  the  scalp. 
He  could  assume  the  characteristic  facial  expression  perfectly,  and  he 
had  various  scars  on  his  head  and  body  to  which  he  was  fond  of  calling 
attention.  Knowing  that  simulators  rarely  fall  so  as  to  hurt  themselves, 
he  once  had  a  fit  in  the  gallery  of  the  prison  and  rolled  off  thirty  feet 
to  the  pavement  beneath,  breaking  one  or  two  bones.  The  reasons  which 
led  to  the  detection  of  his  simulation  were  the  defiinte  motive  he  had  for 
feigning,  the  fact  that  he  had  a  fit  on  the  ]3hysician's  first  visit,  the  way 
he  called  attention  to  his  trouble  and  his  scai-s,  the  change  from  the 
epileptic  to  a  natural  expression  when  he  thought  no  one  saw  him,  the 


FEIGNED  DISEASES  OF  THE  MIND  AND  NERVOUS  SYSTEM.     401 

faet  tlirtt  in  llio  fit  the  fincrei-s  were  not  closed  over  the  thiiinl),  tlie  nails 
wei-e  not  livid,  the  rigidity  could  be  easily  overeome,  the  hands  closed 
ygain  after  they  were  once  opened,  the  sphincters  were  not  relaxed,  and 
finally,  that  there  were  no  ecchymoses,  extravasations,  or  .petechia?  on 
his  jjerson. 

There  is  another  form  of  convulsive  seizure,  however,  which  some- 
times resembles  epilepsy,  3-et  in  which  many  of  the  plienomena  which  in 
epilepsy  suggest  simidation  may  actually  occur.  In  hysterical  attacks 
the  patient  may  have  a  seiziu'e  at  sucli  a  time  as  strongly  to  suggest  the 
desire  for  display,  consciousness  is  not  wholly  lost,  tlie  patient  seldom 
falls  so  as  to  hurt  himself,  and  the  sphincters  are  not  relaxed.  The  grand 
attack  of  h^'steria  is  rare  in  America,  and  its  stages  of  epileptiform  con- 
vulsions, contractions  and  gTaud  movements,  j^lastic  poses  and  passion- 
ate attitudes,  and  delirium,  demand  such  great  knowledge,  such  mimetic 
power,  and  such  extraordinary  muscular  control  that  it  can  seldom  be 
successfully  counterfeited.  In  lesser  attacks  we  nmst  rely  for  the  dem- 
onstration of  the  reality  of  the  affection  partly  upon  the  careful  obseiwa- 
tion  of  the  attack,  but  chiefly  upon  the  disco\'ei"y  of  other  symptoms  of 
Jiysteria.  In  some  cases  we  may  find  regions  where  pressure  will  pro- 
voke an  attack — hysterogenous  zones — or  regions  where  pressui-e  ^vill 
check  an  attack — hysterophrenic  zones — but  such  zones  are  seldom  found 
in  patients  in  this  country.  After  an  hysterical  attack  Gilles  de  la  Tou- 
rette  and  Cathelineau  {La  mdriiion  dans  Vlujsterie)  have  found  that  the 
-amount  of  urine  was  somewhat  decreased  for  the  ensuing  twenty-four 
hom-s,  that  the  solid  constituents  (urea  and  phosphates)  were  one  tlm-d 
less,  and  that  the  ratio  between  the  earthy  and  alkaline  phosphates,  which 
is  normally  from  one  to  three,  rose  to  from  one  to  two  or  even  to  eciual- 
ity.     Wliere  there  are  no  attacks  the  urine  is  usually  normal. 

It  is  important  also  to  determine  the  genuineness  of  the  post-epileptic 
Tinconsciousness,  as  well  as  unconsciousness  arising  from  any  other  cause. 
If  fu'm  pressure  be  exerted  upon  the  supra-orbital  nerve  as  it  emerges 
fi'om  the  notch,  the  pain  soon  becomes  too  great  for  the  simulator  to 
bear.  Similar  results  may  be  obtained  by  the  fai'adic  brush  or  by  the 
needle-point  electrode  witli  a  very  strong  faradic  ciu'rent. 

Contracture. — lu  certain  forms  of  paralysis  contracture  of  the  affected 
limb  becomes  an  important  s^Tiiptom,  but  it  is  impossible  to  feign  it 
successfidly.  On  passive  motion  the  physician  can  at  once  detect  the 
difference  between  the  tonic  rigidity  of  true  contracture,  the  limb  being 
absolutely  stiff  and  yielding  gradually  a  trifle  to  pressure,  and  the  active 
resistance  of  voluntary  musciilar  conti'action  where  the  resistance  is  more 
irregular.  The  attempt  voluntarily  to  resist  passive  movements  will  also 
be  indicated  by  an  increase  in  the  pulse  and  respiration,  flushing  of  the 
face,  and,  if  more  strength  be  applied,  by  the  active  resistance  of  other 
muscles  of  the  body.  In  contracture,  too,  there  is  often  an  increase  in 
the  tendon  reflexes  in  tlie  affected  part. 

In  catalepsy  the  contracture  of  the  muscles  is  of  a  different  type,  the 
limb  is  perfectly  flexible  and  remains  in  whatever  position  it  is  put, 
slowly  and  gradually  falling  after  some  time  by  the  action  of  gravity. 
The  old  experiment  of  Hunter  (Wichmann,  op.  cif.,  p.  54)  may  detect  any 
simulation.  Hunter  hung  a  weight  to  the  arm  of  a  supposed  cataleptic 
by  means  of  a  tape :  the  weight  drew  the  limb  down  very  slowly  and 
gi-adually,  he  suddenly  cut  the  tape,  the  weight  f eU,  and  the  limb  flew  up 


402  ^   SYSTEM  OF  LEGAL  MEDICINE. 

when  the  resistance  to  the  voluntaiy  contraction  was  suddenly  removed^ 
showing  that  the  catalepsy  was  feigned.  Charcot  [Legons  snr  les  mala- 
dies du  systeme  nerveux,  vol.  iii.,  p.  17)  has  demonstrated  by  means  of  a 
registering  aj^paratus  that  if  a  cataleptic  hmb  be  put  in  any  position  it 
^vill  gTadually  fall  by  the  action  of  gravity,  and  that  the  curve  of  descent 
will  be  a  perfectly  even  and  regular  line.  In  feigned  catale]3sy,  however^ 
the  curve  of .  descent  will  be  very  irregular,  the  limb  sinking  and  then 
being  brought  back  again  by  a  sudden  voluntary  effort,  showing  many 
oscillations ;  the  simidator,  too,  will,  after  keeping  a  limb  in  a  given  posi- 
tion mthout  support  for  a  certain  length  of  time,  give  e^ddence  of  his 
effort  by  an  increase  in  the  pulse  and  res]3U'ation. 

Other  forms  of  spasm  are  more  rarely  simulated.  The  feigning  of 
tonic  spasm  may  be  detected  in  much  the  same  way  as  the  feigning  of 
contractui"e.  The  various  forms  of  clonic  spasm,  such  as  tic,  respu*atory 
spasm,  and  the  like,  are  to  be  detected  by  protracted  observation  of  the 
patient  when  he  thinks  himself  unobserved,  or  by  determining  whether 
the  affected  muscles  are  such  as  are  normally  capable  of  such  action 
voluntarily. 

Tremor. — Although  tremor  is  a  comparatively  common  sjonptom  of 
nervous  disease,  its  simulation  is  not  an  easy  matter.  Walton  {Jour. 
Kerv.  and  Ment.  IJis.,  July,  1890),  however,  thinks  that  it  can  be  easily 
simulated,  and  says  that  by  resting  the  hands  on  a  walking-stick  or  table 
a  tremor  of  the  head  may  be  kept  up  for  a  long  time  without  fatigue. 
Other  observers  have  shown  that  tremor  of  the  feet  or  hands  can  some- 
times be  kept  up  by  supporting  some  part  of  the  foot  or  hand  against 
the  wall,  the  bed,  or  a  table.  Such  obvious  methods  of  feigning  should 
deceive  no  one.  Honig  ( Ueier  fSumdafmn  und  Uehertreihung,  p.  30)  has 
reported  a  case  where  the  patient  kept  up  for  some  time  a  tremor  of  the 
legs  by  steadying  the  toes  against  the  foot  of  the  bed,  but  the  tremor  at 
once  ceased  when  the  support  was  taken  away.  Seeligmiiller  {Lehrhucli 
d.  KranTilieiien  des  RiicJienmarJis,  p.  673)  has  suggested  a  method  for  de- 
tecting feigning  in  such  cases.  The  patient  is  put  upon  his  belly  and 
his  feet  are  concealed  fi-om  his  sight ;  if  he  can  press  the  toes  against  the 
bedclothes  or  the  foot  of  the  bed  he  can  in  tins  way  keep  up  a  tremor. 
The  legs  are  then  flexed  at  the  knee  so  that  the  soles  of  the  feet  point 
upward.  In  this  position  Seehgmiiller  claims  that  the  tremor  will  cease 
and  wOl  not  begin  again  until  the  toes  can  once  more  be  touched  to  some 
rough  sui^face  so  as  to  start  it  again.  A  very  rough  form  of  tremor, 
however,  can  be  maintained  with  difficulty  while  the  feet  are  in  the  air, 
and  can  be  started  again  without  pressing  the  toes  on  anything.  Such 
a  tremor,  however,  is  manifestly  artificial.  Real  tremor  cannot  be  feigned 
persistently.  After  a  very  short  time  the  rh}d:hm  of  the  tremor  becomes 
ii'regular,  the  excursions  vary  very  much,  and  as  fatigue  comes  on  the 
effort  to  continue  the  tremor  manifests  itself  in  the  pidse  and  respii"ation. 
Tracings  of  a  simulated  tremor  would  easity  show  the  irregularitj^  Many 
genuine  tremors  may  cease  during  sleep,  so  that  such  a  cessation  is  of 
slight  diagnostic  value.  The  peculiar  tremor  of  the  eyes,  nystagmus, 
cannot  be  feigned  at  all. 

Ataxia,  Choreic  Movements,  etc. — The  various  disordered  move- 
ments, such  as  ataxia  and  chorea,  can  quite  easih^  be  feigned,  but,  when 
genuine,  they  are  usually  associated  A\dth  definite  objective  sj'mptoms.  A 
simulator  can  feign  the  ataxia  and  the  gait  of  tabes,  but  he  cannot  feign 


FEiayJW    DLSKAISES   OF    THE   MINI)  AND  NERVOUS  SYSTEM.     4o;j 

the  conditiou  of  tlie  pu])ils  or  the  loss  of  the  knee-jerk.  The  diajL^nosis 
of  any  condition  will  rarely  depend  upon  these  symptoms  alone,  and  the 
only  certain  method  of  testing  their  genuineness  is  by  protracted  obser- 
vation. 

SENSORY  SYMPTOMS. 

Antesthesia. — The  successful  feig-ning'  of  anaesthesia  is  easy  when 
the  i)atieiit  can  see  what  he  is  about  and  knows  that  the  tests  are  to  be 
applied.  Under  such  circumstaiuces  many  persons  have  nerve  enough  to 
permit  the  cornea  or  the  conjunctiva  to  be  touched  without  winking,  to 
endure  needle-thrusts,  strong  electrical  currents,  or  even  the  hot  iron. 
Most  schoolboys  have  driven  pins  into  themselves  up  to  the  head  with- 
out any  manifestation  of  pain.  It  is  another  matter,  however,  when  the 
tests  are  applied  unexpectedly.  Here,  if  powerful  stimuli  be  used,  the 
patient  will  almost  invarial)ly  start  or  make  some  manifestation  of  sensi- 
bility. Thus  Honig  {op.  cit,  p.  27)  observed  a  simulator  who  made  no 
manifestation  of  pain  at  a  deep  prick  of  a  needle  when  he  knew  that  the 
test  was  going  to  be  applied ;  but  the  next  day,  when  a  needle  was  stuck 
into  him  without  his  knowing  it,  he  at  once  made  an  outcry.  In  a  case 
of  feigned  insanity,  Field  {Jour.  Nerv.  and  Ment.  Dis.,  June,  1890)  saw  nO' 
signs  of  sensibility  when  he  sprinkled  cold  water  on  the  patient  while 
standing  in  front  of  him,  but  the  man  started  when  it  was  unexpectedly 
sprinkled  on  him  from  behind.  Gray  [Treatise  on  Kcrvous  and  Menfal 
J>i.se(i.'^f.s,  p.  146)  has  suggested  accidentally  spilling  very  hot  water  on  the 
alleged  anaesthetic  spot.  Pitres'  case  cited  above  shows  the  practical 
impossibility  of  feigning  auaBsthesia  when  the  tests  are  applied  unex- 
pectedly. 

In  all  cases  where  the  sensibility  is  to  be  tested  the  patient  should  be 
blindfolded.  If,  after  the  ordinary  testing  with  the  tip  of  a  finger  or  a 
camel's-hair  brush,  the  patient  claims  complete  anaesthesia,  the  best  test 
for  demonstrating  the  reality  of  the  autpsthesia  is  the  unexpected  applica- 
tion of  a  powerful  faradic  current  through  a  sharp-pointed  electrode ;  this 
can  be  done  most  easily  while  testing  the  ordinary  electrical  reactions  of 
the  muscles.  An  ordinary  testing  electrode  being  attached  to  one  cord 
of  the  battery,  a  pin  or  a  needle  may  be  thrust  through  the  cord  between 
this  electrode  and  the  battery,  and  concealed  by  the  iiand.  A  large  indif- 
ferent electrode  should  be  attached  to  the  other  cord.  A  faradic  battery 
capable  of  giving  a  very  strong  current  should  be  used.  The  muscular 
reactions  should  be  tested  with  a  mild  current  in  the  ordinary  way,  and 
the  patient's  attention  will  thus  be  distracted  from  any  qui^stion  as  to 
his  sensibility.  While  doing  this  the  current  can  suddenly  be  turned  on 
to  its  full  strength,  and  instead  of  applying  the  electrode,  the  pin  nuiy 
be  applied  to  the  ana?stlietic  spot.  The  pain  of  such  an  application  is  so 
great  that  if  it  be  unexpectedly  applied  the  patient  cannot  refrain  from 
manifesting  his  sensation.  If  the  hand  or  foot  be  anaesthetic,  a  pin  or 
some  other  sharp  instrument  may  lie  pressed  down  under  the  nail  toward 
the  matrix.  If  the  anaesthesia  be  feigned  the  malingerer  will  give  some 
indication  of  his  pain,  either  by  nuiscular  contraction,  an  outcry,  or,  at 
any  rate,  by  an  increase  in  the  rapidity  of  the  pidse. 

If  the  anaesthesia  l)e  limited  to  a  detiuite  ])art  of  the  body  it  is  yv'- 
sumption  in  favor  of  its  genuineness  if  it  be  limited  to  a  definite  periph- 


404  ^  SYSTEM  OF  LEGAL  MEDICINE. 

eral  nerve  distribution  or  to  the  area  of  any  of  the  spinal  segments, 
since  the  average  simnlator  knows  too  little  of  such  distributions  of  an- 
Eesthesia  to  be  likely  to  feign  them. 

If  the  boundary  between  the  anaesthesia  and  the  sensitive  regions 
be  sharply  defined  the  test  becomes  easier.  The  boundary  should  be 
marked  out  mth  a  colored  crayon  before  the  patient  is  blindfolded. 
Then,  after  he  is  blindfolded,  the  skin  on  the  sensitive  side  should  be 
lightly  touched  at  some  distance  from  the  line,  and  the  touches  repeated, 
gradually  approaching  the  line,  until  the  patient  says  he  no  longer  feels 
them.  The  point  where  he  ceases  to  feel  the  touch  should  be  indicated 
by  a  crayon  mark  of  another  color,  and  the  test  repeated.  After  a  new 
boundary  line  has  been  established  in  this  way,  the  skin  on  the  ana?s- 
thetic  side  of  the  hue  should  be  touched  in  the  same  way,  the  touches 
approaching  the  boundary  until  a  point  is  reached  where  the  patient  says 
he  feels  the  touch  ;  this  should  be  marked  with  a  crayon  of  a  third  color 
until  a  boundar}^  line  is  again  established.  If  possible,  the  ]3art  should 
be  covered  and  examination  of  other  parts  be  undertaken,  and  these  tests 
be  repeated  after  an  interval.  If  the  three  lines  agree  the  aufesthesia  is 
undoubtedly  genuine,  for  no  one  can  always  say  correctly  on  which  side 
of  an  imaginary  line  he  is  touched,  when  he  is  touched  close  to  the  line. 
Some  people  can  tell  with  considerable  accuracy  whether  a  touch  is  on 
one  side  or  the  other  of  the  median  line,  but  they  cannot  tell  in  regard 
to  lines  elsewhere,  especially  the  cm-ious  boundary  lines  of  the  geometri- 
cal anaesthesias  occasionally  seen  in  hysteria  or  of  the  anesthesias  from  a 
peripheral  nerve  lesion  or  from  the  lesion  of  a  spinal  segment.  "  If  this 
boundary  hue  pass  through  one  of  the  less  sensitive  regions  of  the  skin 
its  genuineness  is  still  more  probable,  for  it  is  still  harder  to  say  on  which 
side  of  an  imaginary  line  a  touch  is  made  in  such  regions.  Bui'ghardt 
{PraJctische  Diagnostih  der  Simulafionen  der  GefiiJilsldhnmng,  Schwerhorig- 
Tieit,  und  Schivachsichfigl-eit)  has  suggested  that  when  the  boundary  lines 
are  found  to  disagree  they  be  shown  to  the  patient  and  a  new  test  made, 
but  the  advantage  of  this  is  not  apparent.  Burghardt  has  also  suggested 
that  the  patient  be  told  to  indicate  by  raising  the  finger  whenever  he  is 
touched,  claiming  that,  if  the  touches  be  rapidly  made,  the  malingerer 
will  sometimes  indicate  when  the  anaesthetic  region  is  touched.  In  most 
cases,  however,  it  is  difficult  to  get  an  ordinary  patient  to  lift  the  finger 
quickly  enough  to  make  tliis  test  very  practical.  The  compasses  may 
be  useful  in  testing  the  relative  sensibility  of  two  different  j>arts  of  the 
body,  but  their  use  requires  very  much  time,  and,  as  a  rnle,  the  results 
obtained  by  them  are  hardly  worth  the  trouble.  Goldscheider  has  sug- 
gested another  method  of  testing  the  genuineness  of  anaesthesia  when  its 
boundary  is  sharply  defined.  A  ^vire  brush  electrode  or  Erb's  farado- 
cutaneous  electrode  is  placed  on  the  boundary  line  and  the  faradic  cm'reut 
passed  through  it.  When  evenly  pressed  upon  the  bod}^  the  patient  will 
of  course  feel  the  current  in  the  sensitive  region,  but  if  it  be  slightly 
tipped  it  may  be  made  to  rest  almost  wholly  on  the  anaesthetic  tenitory 
without  the  patient  observing  it  has  been  tijiped.  If  then  he  states  that 
he  still  feels  the  current  the  probabilities  are  tbat  his  anaesthesia  is  feigned. 

In  most  cases  of  anaesthesia  the  skin  reflexes  are  lost  or  diminished 
in  the  affected  part.  In  hysterical  conditions,  too,  some  of  the  reflexes 
from  the  mucous  membranes  may  disappear ;  a  loss  of  the  pharyngeal 
reflex  is  especially  common. 


FEIGNED  DISEASES   OF  THE  MIND  AND  NERVOUS  SYSTEM,     405 

Wliile  these  tests  are  sufficient  to  demonstrate  clearly  the  genuine- 
ness of  anaesthesia,  we  cannot  always  say,  if  the  tests  fail,  that  the  an- 
ajsthesia  is  feigned ;  for  in  hysteria,  as  is  well  known,  the  boundaries  of 
the  anaesthetic  region  may  shift  rapidly,  and  in  certain  forms  of  ana'S- 
thesia  the  application  of  electricity  is  of  itself  sufficient  to  change  the 
extent  of  the  anaesthesia,  perhaps  to  diminish  it,  and  in  hysterical  cases 
the  intluen(,*e  of  suggestion  may  sometimes  be  so  great  that  under  ex- 
amination the  auiTestliesia  may  increase,  diminish,  or  perhaps  be  trans- 
ferred to  the  other  side.  Fiu-thermore,  it  is  now  recognized  that  hyster- 
ical ana?sthesia  is  distinctly  of  psycliical  origin,  that  the  patient  actually 
feels  a  touch  or  a  prick  in  the  ana?sthetic  limb,  and  that  by  hypnotism, 
or  in  other  ways,  the  patient  may  be  made  to  state  definitely  where  and 
how  many  times  he  has  been  touched.  All  these  facts,  therefore,  must 
be  duly  considered  before  we  state  positively  that  an  ana?sthesia  is  feigned. 

Of  other  forms  of  am-esthesia  it  is  not  necessary  to  speak  in  much 
detail.  The  tests  already  mentioned  will  reveal  any  analgesia,  which 
may  occur  with  normal  sensibility  to  touch.  Few  simulators  are  likely 
to  know  enough  to  feign  thermanaesthesia.  If  the  temperature  sense  be 
carefully  tested  by  metal  rods  of  different  temperature,  according  to  the 
method  described  by  Goldscheider  {Biagnosfik  der  Kercexl-mnlJieiten, 
p.  33),  and  there  be  a  distinct  diminution  to  either  heat  or  cold  in  one 
region  as  compared  with  that  of  the  opposite  side,  the  spnptom  is  very 
apt  to  be  genuine,  although,  of  course,  the  success  of  such  a  test  is  not 
an  absolute  proof.  The  unexpected  application  of  very  cold  or  very  hot 
water  will  usually  elicit  signs  of  sensibility  if  the  thermana^sthesia  be 
feigned.  Few  patients,  too,  have  sufficient  knowledge  to  feign  distiu'b- 
ances  of  the  muscular  sense,  and,  if  they  should,  it  is  usually  possible,  on 
protracted  observation,  to  discover  that  the  patient  knows  more  in  regard 
to  the  position  and  the  movements  of  his  limbs  than  he  claims.  It  must 
be  borne  in  mind  that  a  genuine  ana?sthesia  can  be  temporarily  produced 
by  the  application  of  belladonna,  cocaine,  and  other  drugs.  If,  however, 
the  area  of  the  anesthesia  be  extensive,  it  is  not  probable  that  it  is 
caused  by  the  application  of  such  drugs ;  for  if  they  were  used  in  amount 
sufficient  to  produce  ana?sthesia  of  such  an  extent,  there  would,  in  all 
probability,  be  pronounced  signs  of  their  physiological  action. 

Pain  and  Hyperaesthesia. — Since  pain  is  a  symptom  of  almost  every 
disease,  and  since,  moreover,  it  is  a  purely  subjective  symptom,  it  is  not 
strange  that  it  is  one  of  the  chief  symptoms  complained  of  by  malinger- 
ers. Of  the  truth  or  falsehood  of  such  a  complaint  we  have  no  absolute 
method  of  judging,  but  in  many  cases  we  can  find  some  confirmatory 
evidence  from  other  symptoms  to  aid  us  in  forming  an  opinion.  If,  for 
instance,  the  patient  complains  of  lancinating  pains,  and  Ave  find  object- 
ive signs  of  tabes,  or  if  the  pain  be  referred  to  a  given  nerve  distribution, 
and  we  find  VaUeix's  tender  points  or  changes  in  the  reflexes,  we  can 
assume  the  pain  to  be  real.  In  cases,  however,  where  there  is  no  other 
evidence  of  disease,  we  cannot  come  to  a  definite  conclusion,  excepting 
that  if  the  patient's  claim  of  severe,  extreme,  and  continued  pain  be  true 
it  will  often  be  manifested  by  disturbed  sleep  and  impaired  nutrition. 

With  regard  to  tenderness,  however,  Mannkopf  and  'Rnm.-pt  {CoitralhJ. 
f.  Xervenheill-.,  No.  12,  1889)  have  suggested  a  procedure  which  often 
enables  us  to  say  definitely  that  the  tenderness  is  real.  If  firm  pressure 
be  made  upon  a  tender  spot,  the  pain  will  often  cause  an  increase  in  the 


406  ^   SYSTEM  OF  LEGAL  MEDLCIXE. 

pulse  rate,  sometimes  as  mncli  as  twenty  beats  a  minute.  In  some  cases, 
there  may  be,  in  addition  to,  or  instead  of,  an  increase  in  tlie  rapidity  of 
tlie  pulse,  a  weakening  of  tlie  pulse,  a  fiusliing  of  tbe  face,  or  an  outburst 
of  sweat  on  the  forehead.  If  there  be  no  increase  in  the  pulse,  however, 
we  cannot  say  that  there  is  no  tenderness,  for  in  cases  of  real  disease  the 
pulse  is  sometimes  unaffected,  especially  if  the  tenderness  be  slight.  In 
many  cases,  however,  I  have  been  able  to  demonstrate  the  reality  of  ten- 
derness by  this  means.  It  is  needless  to  say  that  the  patient  should  have 
no  idea  of  the  test  to  be  applied,  and  it  is  also  better  that  he  should  be 
blindfolded. 

SPECIAL   SENSES. 

Vision. — The  detection  of  feigned  visual  distm-bances  is  a  compar- 
atively easy  matter.  The  feigning  of  complete  blindness  of  both  eyes- 
demands  great  perseverance  and  unusual  skill  in  order  to  counterfeit  the 
general  demeanor  of  a  blind  person  and  the  rigid,  unaltered  look  to  the 
eyes,  which  does  not  vary  at  any  visual  impression.  Few  have  sufficient 
control  to  remain  unmoved  when  objects  are  closely  approximated  to  the 
eyes.  If  a  large  object,  however,  be  suddenly  brought  before  the  eyes 
even  of  a  blind  man,  the  ciu-rent  of  air  engendered  by  the  movement  may 
cause  him  to  make  some  motion  of  defense.  Sudden  and  unexpected 
movements  in  the  neighborhood  of  one  who  is  feigning  blindness,  espe- 
cially threatening  movements,  may  lead  him  to  make  some  unexpected 
movement  which  indicates  that  he  sees.  Protracted  observation  will  also 
show  that  he  has  not  the  characteristic  habits  of  a  blind  man,  and  that 
he  is  governed  by  his  eyesight  when  he  is  moving  about  a  room  and 
thinks  himself  unobserved. 

Burghardt  {op.  cif.)  has  suggested  a  method  of  detecting  feigned  blind- 
ness. The  patient  is  asked  to  put  out  one  finger  and  then  to  touch  it 
with  the  other.  A  person  who  is  actually  blind  can  do  this  perfectly 
well ;  the  simulator  is  yery  apt  to  overact  the  part  and  not  to  touch  it 
correctly.  Bm-ghardt  then  had  an  attendant,  with  bandaged  eyes,  do  it 
in  the  presence  of  a  simulator,  and  the  next  day  the  simulator  succeeded 
in  doing  it  perfectlj^  well.  Ai'lt  (HeUer,  oj).  cif.,  p.  73)  has  pointed  out 
that  in  feigned  bliudness,  if  we  throw  a  strong  light  into  the  eye  so  that 
it  strikes  the  macula,  after  a  time  the  eye  becomes  restless  and  tears  be- 
gin to  flow.  In  such  a  case  we  might  properly  suspect  there  was  percep- 
tion of  light.  If,  however,  this  experiment  be  tried  in  an  eye  which 
has  even  a  slight  perception  of  light,  the  same  effect  may  be  produced, 
and  error  maj^  arise.  Such  experiments,  hoM^ever,  are  seldom  necessary. 
There  are  very  few  cases  of  blindness  in  wliich  the  ophthalmoscope  wiU 
not  reveal  definite  structural  changes  in  the  optic  nerve,  the  retina,  or 
the  conducting  media.  If  the  eye  be  normal  in  an  ophthalmoscopic  ex- 
amination, and  if  tliei'e  be  no  renal  disease,  oiu*  suspicions  may  properly 
be  awakened.  In  a  few  cases  of  optic  neuritis,  or  of  optic  atrophy,  blind- 
ness may  precede  any  changes  in  the  eye  itself.  Von  Graefe  (HeUer, 
op.  ('it.,  p.  73)  states  that  atrophy  may  occur  six  months  after  the  cessation 
of  any  sensation  of  light ;  but,  on  the  other  hand,  we  see  many  cases  of 
neuritis  and  partial  atrophy  where  considerable  \asual  power  is  still  re- 
tained, and  in  cases  of  atrophy  peripheral  limitation  of  the  visual  field 
may  precede  the  visible  signs  in  the  retina. 

Heller  {op.  cit.,  p.  74)  claims  that  the  simulation  of  unilateral  blindness 


lEiaXEl)  DISEASES   OF  THE  MIND  AND  NERVOUS  SYSTEM.     4()7 

is  miicli  more  common  tlian  tliat  of  complete  blindness,  as  it  is  naturally 
much  less  iniplcasant  for  the  simulator.  P^ven  in  such  a  case  simulation 
is  exceediuii^ly  improba.ltlc,  since  changes  would,  in  all  pro])ahility,  be  found 
by  the  ophtlialmosc()[)e  in  the  bUnd  eye.  If  blindness  of  one  eye  J^e  feig-ned, 
however,  it  can  usiuilly  ha  cpiite  readily  detected  by  means  of  prisms  or  by 
.siniilar  tests.  The  simi)lest  method  is  that  proposed  by  Von  Graef e  (Archio 
f.  OpJUh.,  vol.  ii.,  p.  2()G).  The  prism,  of  from  six  to  twelve  degrees,  with 
its  base  turned  upward  or  downward,  is  placed  before  the  healthy  eye. 
If  the  lianie  of  a  candle,  or  a  small  dot  or  a  fine  line  upon  a  paper,  be  seen 
douljle,  the  simulation  is  at  once  proven.  We  may  also  tr}'  whether  the 
double  image  moves  during  the  rotation  of  the  prism j  or  whether  the 
-double  image  disappears  upon  the  reestablishment  of  binocular  vision 
by  turning  the  base  of  the  jjrism  outward.  If  the  simulator  be  shrewd 
•enough  to  know  that  one  of  these  images  belongs  to  the  pretended  blind 
eye,  we  nuiy  hold  a  prism  which  refracts  vertically  before  the  normal  eye 
.so  that  its  refracted  angle  will  bisect  the  j)upil.  In  this  way,  when  the 
alleged  blind  eye  is  covered,  monocular  diplopia  may  be  produced :  if 
the  simulator  deny  this  diplopia,  there  is  good  reason  to  doubt  his  state- 
ments ;  if  he  admits  it,  it  can  very  easily  be  made  into  binocular  diploj^ia 
by  uncovering  the  pretended  blind  eye  and  moving  the  prism  slightly  so 
that  it  shall  cover  the  whole  pupil.  Feigned  blindness  of  one  eye  can 
.also  be  detected  by  the  stereoscope.  As  is  well  known,  in  binocular 
vision  through  the  stereoscope  the  fields  of  the  two  eyes  are  united  into 
■one,  Rabl-Riickhard  {Deutsche  militdr-arztl.  Zeitschr.,  1874)  has  recom- 
mended that  we  should  put  into  the  stereoscope  a  figure  which  should 
have  a  circle  in  each  field ;  in  normal  vision  through  the  stereoscope  the 
two  circles  would  blend  into  one,  forming  a  single  object,  which  may 
.serve  as  a  fixation  point.  By  ai-raugiug  the  cards  so  that  other  figures 
can  be  moved  about  in  the  field  in  varying  positions,  the  simulator  can 
readily  be  led  astray,  for  an  object  in  the  right  half  of  the  left  field  will 
lie  on  the  right  side  in  the  common  field,  and  the  patient  cannot  tell 
whether  he  sees  it  with  the  right  eye  or  mth  the  left. 

It  must  be  borne  in  mind,  however,  that  there  are  genuine  cases  of 
hysterical  blindness  of  one  eye,  where  the  patient  can  really  see  with  the 
eye  that  seems  to  be  blind.  Pitres  (oj).  cit.,  vol.  i.,  p.  103)  states  that  an 
•oculist  once  said  to  him  that  every  case  of  hysterical  Ijlindness  was  fraud- 
ulent. Pitres  himself  demonstrated  the  plausibilitj'  of  this  by  placing  a 
.screen  perpendicularly  between  the  two  eyes,  and  holding  in  front  of  the 
patient  a  card  with  a  line  of  printed  letters.  "When  the  blind  (left)  eye 
was  closed  the  patient  could  see  with  the  right  eye  only  the  lettei'S  to  the 
right  of  the  screen ;  when  the  right  eye  Avas  closed  no  letters  at  aU  were 
perceived ;  when  both  eyes  were  open  the  patient  could  read  not  only  the 
letters  to  the  right  of  the  screen,  but  also  the  letters  to  the  left  of  the  screen, 
showing  conclusively  that  the  letters  were  perceived  with  the  left  eye. 
This  agrees  with  the  conditions  which  have  been  spoken  of  under  anaes- 
thesia, where  it  has  been  shown  that  the  patient  actually  feels  a  touch  in 
some  of  the  forms  of  hysterical  anaesthesia ;  and  as  this  has  been  demon- 
strated in  many  cases  where  there  is  no  reason  to  doubt  the  genuineness 
of  the  hysterical  symptoms,  we  niiist  consider,  as  Pitres  does,  that  in 
hysterical  blindness  of  one  eye  the  blindness  exists  only  with  monocular 
vision.  In  such  cases  the  other  s,ymptoms  of  hysteria  wiU  usiuiUy  be 
present,  so  that  we  can  make  an  accurate  diagnosis. 


408  ^  SYSTEM  OF  LEGAL  MEDICIXE. 

The  detection  of  poor  vision  is  somewhat  more  difficult.  In  most 
cases,  however,  there  are  distinct  phj'sical  conditions  in  the  eye  to  ac- 
count for  snch  vision.  Possibly  in  such  conditions  there  may  be  some 
corneal  oj^acities,  retinitis  pigmentosa,  etc.,  or  else  the  failm-e  of  vision 
ma}''  be  dne  to  errors  of  refraction.  In  the  latter  case  these  errors  can 
be  readily  determined.  If  the  patient  makes  false  statements  in  regard 
to  the  ordinary  test  with  lenses,  a  degree  of  refractive  erro]-,  amonnting 
from  one  half  to  one  diopter,  can  be  determined  by  a  skilled  observer 
with  an  ophthalmoscope,  or  by  the  shadow  test,  if  the  patient's  accom- 
modation be  paral3"zed  hy  atropine,  and  refraction  errors  of  less  than 
one  diopter  cannot  have  a  Y&ry  marked  effect  npon  the  vision. 

Hemeralopia  is  sometimes  feigned  by  soldiers.  In  examining  this 
condition  the  patient  is  made  to  look  into  a  dark  chamber  at  various 
objects.  By  means  of  a  sliding  shutter,  the  chamber  can  be  more  and 
more  illnminated,  and  the  degree  of  light  gradually  increased  until  the 
patient  says  he  can  see  the  objects  upon  the  test-card.  A  simulator  can 
seldom  give  consistent  and  accurate  statements. 

Feigning  of  color-blindness  can  usually  be  detected  by  the  ordinary 
worsted  test.  Unless  the  patient  be  thorougldy  experienced  in  the  mis- 
takes which  the  color-blind  make,  he  wiU  put  together  worsteds  of  colors 
which  no  color-blind  person  woidd  confuse. 

In  many  cases  of  alleged  defective  vision  very  much  can  be  learned 
by  a  careful  examination  of  the  field  of  vision.  Various  investigations 
in  hysteria  and  the  so-called  traumatic  neuroses  have  given  added  weight 
to  the  changes  in  the  visual  field.  No  satisfactory  results,  howe\'er,  can 
be  obtained  without  a  careful  investigation  by  means  of  the  perimeter, 
and  in  man}'^  cases  the  field  shoidd  be  tested  not  only  for  form  but  also 
for  color.  If  there  be  hemianopsia  there  "udll  usually  be  other  sj-mptoms 
to  confirm  the  diagnosis,  such  as  ana?sthesia,  paralysis,  or  the  hemiopic 
pupil  reaction.  In  many  forms  of  disease,  including  the  initial  stages 
of  optic  atrophy,  hysterical  amlilyopia,  and  other  affections,  there  "v^all  be 
a  concentric  limitation  of  the  field.  If  the  perimeter  be  placed  so  that 
the  light  comes  from  behind  the  patient's  back,  and  the  patient  be  facing 
a  uniform  dark  sm-f ace,  it  is  impossible  for  him  to  feign  successfidly  the 
concentric  limitation  as  tested  on  the  perimeter.  The  outline  of  a  feigned 
contracted  field,  as  Oppenheun  [Vt^eitere  Miffheilungeii  in  Bezug  auf  die 
Tranmatisclien  Nenrosen,  p.  43)  has  shown,  ynR  be  irregular,  and  much 
greater  in  some  meridians  than  others.  Fiu-thermore,  on  repeated  tests 
the  simulator  cannot  feign  the  same  contraction.  Should  doubt  arise, 
we  may  adopt  the  method  suggested  by  Wilbrand  and  Saenger  ( Ueher 
Sehsfo)-u)ige)i  hei  fioictioiiellen  Kerrenleiden,  p.  189),  and  test  the  field  by 
perimeters  of  different  diameters.  This  renders  it  practically  impossible 
to  simulate  I'epeatedly  a  contracted  field  which  shall  lia^'e  the  same  ex- 
tent and  outline. 

Hearing. — lu  the  great  majority  of  cases  of  actual  deafness  a  careful 
examination  of  the  ear  by  means  of  the  aui'al  specidum  will  reveal  the 
cause,  unless  the  deafness  be  due  to  lesion  in  the  auditory  nerve  or  the 
labyrinth.  Should  there  be  a  motive  for  simidation,  and  should  any 
changes  be  found  on  examination,  deafness  may  usually  be  detected  hy 
protracted  observation.  The  simulator  seldom  knows  enough  to  distin- 
guish between  the  vibratory  sensations  Avhich  are  conveyed  to  his  sense 
of  feeling  by  loud  noises  and  those  which  are  conveyed  to  the  sense  of 


FEiayEl)    niSKASlCS    of   the    mind  AXD   nervous  system.     4(J9 

lieariii*;'  by  tlio  same  noises,  aiul  lie  will  often  den}'  any  sensation  \\ijat> 
ever.  The  simulator  may  also  start  at  unexpected  noises,  and  may  be 
aroused  t'l-om  sleep  by  a<  loud  noise,  or  when  drunk  or  under  the  influence 
of  an  amesthetic  he  may  answer  (juestions  that  are  put  to  him. 

Heller  {op.  cit.,  p.  10,'})  has  sng-gested  that  simulated  deaf-diimbness 
may  be  detected  by  a  person  who  is  genuinely  deaf  and  dumb,  or  by  a 
teacher  of  the  deaf  and  dumb,  owing-  to  the  failure  of  the  simulator  ac- 
curately to  feign  the  behavior  of  a  genuine  deaf-dumb  person.  Further- 
more, if  the  simulator  be  uneducated,  and  attempt  to  Write,  lie  will  not 
spell  his  words  correctly,  but  will  l)e  ai)t  to  spell  them  as  they  are  pro- 
nounced, whereas  the  deaf  and  dunil)  person  will  not  be  guided  by  the 
sound  of  the  word,  but  will  spell  it  as  he  has  been  taught. 

Absolute  deafness,  however,  is  not  so  likely  to  be  feigned  as  jiar- 
tial  deafness,  and  it  is  a  well-known  fact  that  in  partial  deafness  the 
power  of  hearing  may  vary  very  gi-eatly  from  time  to  time.  In  gen- 
uine cases  of  partial  deafness  there  are  usually  definite  changes  in  the 
ear.  The  simulator  often  fails  to  imitate  the  characteristic  expression 
of  a  deaf  person.  Casper  long  ago  suggested  a  method  of  examination 
which  is  of  some  value.  A  sentence  should  be  begun  in  a  very  loud 
voice,  and  the  voice  gradually  loAvered.  The  simulator  will  often  he  con- 
fused l)y  this  simple  experirneut.  Burghardt  {op.  cit.)  has  suggested 
another  method  of  some  value.  One  ear  is  closed  and  the  patient  is  put 
at  such  a  distance  that  he  cannot,  as  he  claims,  hear  the  ordinary  spoken 
voice,  the  eyes  lieing  blindfolded ;  a  tube  is  put  in  the  affected  ear,  tlirough 
whicli  the  patient  can  still  hear.  If  How  the  tube  be  closed  suddenly, 
without  the  patient  hearing  it,  and  lie  still  hears  the  spoken  word,  he 
hears  it  through  the  air,  and  his  previous  statement  Avas  incorrect. 

Unilateral  deafness  is  also  occasionally  feigned.  If  there  are  no 
changes  to  l)e  found  in  the  ear  itself,  this  may  be  detected  in  various 
waj's.  Erhardt  {Deufaclie  miJitUr-in-zt.  Zeif.scJu:,  1872)  has  pointed  out 
that  the  sound  of  a  repeater  may  be  heard,  even  when  the  ear  is  closed 
by  the  finger,  at  a  distance  perhaps  of  ten  feet.  If  the  repeater  be  held 
six  or  eight  feet  in  front  of  the  sound  ear  the  patient  naturally  hears  it 
perfectly  well ;  if  that  be  closed  and  it  be  brought  within  fom*  feet  of  the 
ear  which  is  said  to  be  deaf,  and  the  simulator  says  he  no  longer  hears 
it,  the  chances  are  that  his  statements  are  incorrect.  The  best  method 
of  detecting  simulation  of  one-sided  deafness,  however,  is  a  modification 
of  the  experiment  described  by  Coggin  {Zeitschr.  f.  Olwenheilk.,  vol.  viii.). 
Coggin  suggests  that  the  ordinary  binaural  stethoscope  be  used.  By  this 
means  the  object  is  brought  rather  too  near  the  ears  for  careful  testing, 
and  the  experiment  should  be  modified  so  that  the  binaural  stetho- 
scope can  be  used  with  much  longer  tubes,  the  patient  sitting  several 
feet  away  from  the  testing-object.  With  tlu^  stethoscope  placed  in  the 
ears  it  may  then  be  possible,  without  the  patient's  knoM'ledge,  to  close 
one  or  the  other  of  the  couducting-tubes;  the  sound  is  conve^'cd  either 
to  the  sound  ear  or  to  the  alleged  deaf  ear  at  the  will  of  the  examiner, 
without  the  patient's  knowledge,  and  the  simulator  can  in  this  way  be 
readily  led  to  make  contradictory  statements. 

Disturbances  of  smell  and  taste  are  of  extremely  slight  importance, 
and  we  have  no  absolute  means  of  testing  them  apart  fi'om  the  state- 
ments of  the  patient. 


410 


A   SYSTEM  OF  LEGAL  MEDICINE. 


SPEECH   DISTURBANCES. 


Feigning  of  speech  disturbances  is  extremely  rare.  The  most  com- 
mon form  is  the  feigning  of  absohite  dumbness.  Genuine  acquired 
dumbness  occurs  only  in  hysterical  mutism,  where  the  patient  is  un- 
able to  make  any  sound  whatever.  In  the  loss  of  speech  of  aphasia 
the  patient  makes  various  inarticulate  sounds.  True  aphasic  disturb- 
ances, such  as  word-blindness,  word-deafness,  motor  aphasia,  and  para- 
phasia demand  extreme  skill  upon  the  part  of  the  simulator,  and  in 
the  vast  majority  of  cases  they  are  associated  with  hemiplegia.  Feigned 
mutism  is  occasionally  seen  as  one  of  the  symptoms  of  feigned  insanity, 
but  in  these  cases  protracted  observation  will  usually  give  the  opportu- 
nity for  revealing  the  patient's  deception,  and  lead  him  into  making  some 
unguarded  remark. 

FEIGNED  INSANITY. 

From  the  old  statement  of  Zacchias,  "  N-uIIus  morhns  facUins  et  fre- 
quentius  simuJari  solet  qiiam  insania,^'  to  that  of  Kiilm  {ArcMv  f.  PsycMa- 
trie,  vol.  xxii.,  p.  649),  that  the  number  of  simulants  of  insanity  are  in 
inverse  ratio  to  the  physician's  psychiatric  knowledge,  is  a  long  step,  but 
it  shows  both  the  increase  in  our  knowledge  of  insanity  and  the  change 
of  medical  opinion  in  regard  to  feigning.  Even  at  the  present  time, 
however,  although  all  physicians  regard  feigned  insanity  as  rare,  there 
is  not  general  harmony  as  to  its  absolute  frequency.  Thus  Schiile,  in 
the  second  edition  of  his  Klimsclie  PspcMatrie,  stated  that  he  had  never 
seen  a  case.  Fritsch  {JahrUicJier  f.  Psycliiatrie,  vol.  viii.,  p.  115)  saw  but 
one  case  out  of  3800  in  Meynert's  clinic,  and  Moeli  ( TJeber  irren  Verhrecher) 
and  Sander  and  Richter  {Die  Beziehungen  zivischen  Geistesstdrung  und  Ver- 
hrechen)  have  all  considered  feigning  as  extremely  rare.  It  may  be  said, 
however,  that  these  figures  are  taken  chiefly  from  the  statements  in  regard 
to  general  insane  asylums  and  the  ordinary  clinics  for  mental  disease ; 
but  Fiirstner  {Arch.  f.  Psych.,  vol.  xix.,  p.  601)  has  urged  that  if  statistics 
were  taken  from  criminal  asylums,  or  from  the  cases  of  alleged  insanity 
among  criminals,  it  would  be  found  that  feigned  insanity  was  not  so 
very  uncommon.  Fiirstner  himself  found  12  cases  out  of  25.  Holmboe 
(¥orsk  Magazin  f.  Laegevklensk,  No.  2,  1893)  found  1  case  in  21.  SneU. 
{AUg.  Zeitschr.  f.  Psych.,  vol.  xliv.,  p.  4)  considered  feigning  not  rare,  and 
Binswanger  (cited  by  Fiirstner)  found  21  cases  out  of  73.  Kiihn  {art. 
dt.,  p.  650),  on  the  contrary,  who  had  the  opportunity  of  observing  over 
10,000  criminals,  and  had  investigated  nearly  150  cases  of  insanity  occur- 
Ting  among  them,  saw  but  two  who  had  simulated.  The  figures  already 
given  from  Massachusetts  prisons  would  indicate  that  feigning  of  insan- 
ity by  criminals  was  distinctly  rare.  It  must,  however,  be  again  noted 
that  at  the  Chai-lestown  State-prison  there  were  many  attempts  at  feigning, 
which  were  readily  detected  by  the  prison  physician  without  the  need  of 
calling  in  a  special  examiner  in  lunacy.  In  the  vast  majority  of  cases 
insanity  will  be  simulated  only  by  ih.Q  criminal,  although  Nichols  {Boston 
Med.  and  Surg.  Journal,  April,  1891)  has  reported  one  case  of  a  boy  who 
.simulated  dementia  in  {\\e  hope  of  obtaining  damages  on  account  of  a  rail- 
way accident.     It  must,  however,  be  borne  in  mind  that  the  percentage  of 


FEW y ED   DISEASES   OF   THE   MF\D  AND  NEll VOL'S  SYSTEM.     4]^ 

actual  iusaiiity  among  criniinals  is  j)robably  much  gi-eater  than  it  is  in 
the  community  at  hirge.  Not  only  is  the  criminal  more  exposed  to  the 
various  acquired  injurious  factors  which  may  produce  insanity,  but  often, 
as  is  well  known,  he  is  himself  degenerate  and  comes  of  a  bad  heredity. 
Even  if  we  do  not  accept  the  theories  of  Lomljroso  that  the  actucd  crim- 
inal must  be  regarded  as  mentally  diseased,  the  evidence  in  favor  of  his 
degeneracy  is  too  great  to  be  absolutely  neglected ;  and  this  is  often 
shown,  not  only  in  his  mental  characteristics,  but  also  in  many  of  the 
physical  characteristics.  More  than  one  case  indeed  is  upon  record  where 
a  criminal  who  already  had  one  form  of  insanity  simulated  another  form  ; 
and  many  writers  agree  with  Fritsch  that  the  simulation  of  mental 
disturbance  is  very  rarely  seen  in  healthy  individuals,  and  that,  in  gen- 
eral, the  hypothesis  is  not  unjustifiable  that  simulation  points  ^ith 
some  probabihty  to  a  coexisting  neuropatliic  disposition  or  psychopathic 
taint,  or  that  it  may  be  brought  into  relation  with  previous  conditions 
of  so-called  degeneration. 

Sander  and  Richter  {op.  cit.)  have  called  attention  to  the  fact  that  in 
•criminals  who  are  actually  insane  the  type  of  mental  disease  often  shows 
peculiar  mixed  forms,  which  are  peculiar  as  to  theii*  natm-e  and  their 
periodicity,  and  are  mai-ked  by  ii-regularity  and  lack  of  harmony  in  the 
symptoms.  Frits(;li  has  pointed  out  that  much  may  seem  simulated 
wliich  really  is  not  so,  and  cites  the  case  of  a  young  man  who  was 
repeatedly  arrested  for  various  crimes,  who  presented  a  peculiar  com- 
bination of  symptoms,  characterized,  fii'st,  by  a  peculiar  gait  and  ges- 
ticulations, ^^dth  periods  of  silence,  then  by  various  delusions  of  a 
hypochondriacal  type,  which  were  uot  at  all  in  harmony  with  one 
another,  and  gave  rise  to  much  suspicion  of  malingering;  yet  pro- 
tracted observation  finally  showed  a  distinct  underlying  condition  of 
paranoia.  We  must  consider,  therefore,  that  even  the  attempted  simu- 
lation of  insanity  is  rare,  and  that  in  few  cases,  if  the  physician  have 
any  experience,  is  it  ev^er  successful.  In  many  cases  it  is  difficult  to 
make  an  absolute  diagnosis  of  insanity  from  a  single  examination,  and 
when  there  is  reason  to  suspect  simulation  a  period  of  protracted  obser- 
vation in  an  asylum  may  be  necessary. 

From  what  has  ah-eady  been  said  the  difficulty  of  simulation  is  appar- 
ent. Krafft-Ebing  {Lehvlmcli  d.  gericlitl.  FmchopatlwJoijie,  p.  42)  has  em- 
phasized this.  The  simulator  is  in  some  respects  like  an  actor :  but,  unlike 
an  actor,  he  must  be  an  author  as  well,  and  he  must  also  constantly  be 
an  im]n'oviser ;  his  acting,  moreover,  must  be  incessant,  even  if  he  thinks 
himself  unobserved.  A  simulator  must  also  act  before  an  audience  of 
trained  critics  who  cannot  be  diverted  from  his  performance ;  conse- 
quently, he  must  become  exhausted  after  a  few  hours,  and  the  mental 
strain  of  such  a  performance  may  in  itself  be  a  cause  of  mental  break- 
down. 

The  absurd  attempts  to  depict  insanity  in  the  majority  of  novels  well 
sliow  the  false  ideas  which  are  usually  held  in  i-egard  to  mental  diseases. 
The  lunatic,  according  to  popular  belief,  is  either  raving  or  so  demented 
tliat  he  is  incapable  of  any  sensible  act  or  woi-d. 

In  a  few  cases,  of  eom'se,  tlie  simulator  may  have  had  the  opportunity 
of  associating  with  the  insane  and  of  studying  their  symptoms  with  care. 
In  such  cases  the  portrayal  of  insanity  may  sometimes  be  sufficiently 
Tealistic  as  to  cause  considerable  doubt  as  to  the  actual  condition.    In  ordi- 


412  -4   SYSTEM  OF  LEGAL  MEDICINE. 

nary  cases,  however,  where  tliis  opportunity  for  special  study  is  absent^ 
the  simulation  is  so  grossly  exaggerated,  and  so  entirely  unlike  the  be- 
havior of  a  person  who  is  actually  insane,  that  it  can  be  readily  de- 
tected, the  simulator  seldom  presenting  symptoms  which  correspond  to 
any  particular  form  of  insanity.  As  a  rule,  the  symptoms  of  simulated 
insanity  begin  suddenly,  developing  upon  a  period  of  apparent  mental 
health ;  the  slight  j)rodromal  stages,  wliich  can  usually  be  elicited  in  ordi- 
nary cases,  are  lacking.  In  most  of  the  attempts  at  feigning  insanity 
at  the  Charlestown  Prison,  the  prisoners  began  by  being  very  noisy  and 
demonstrative,  or  else,  less  frequently,  they  began  by  some  lascivious 
act,  such  as  exposiu"e  of  the  person.  The  simulator  usually  grows  worse 
under  examination,  and  at  other  times  he  watches  the  acts  of  the  physi- 
cians and  attendants  in  a  way  which  is  seldom  seen  excejjt  in  some  cases 
of  paranoia.  He  also  fears  to  be  too  reasonable  ;  he  has  no  memory  of 
anything ;  he  is  never  coherent ;  in  the  c|uiet  periods  of  his  insanity  he 
knows  nothing ;  he  manifests  no  logical  reasoning  and  no  association  of 
ideas.  The  case  of  a  man  reported  by  Krafft-El^ing  {Jahrhilcher  f.  Fsy- 
cJiiatrie,  vol.  viii.,  p.  293)  who  simulated  dementia,  deafness,  and  dumb- 
ness, shows  some  of  these  peculiarities.  The  patient  suddenly  became 
demented,  deaf,  dumb,  and  did  not  react  at  all  to  external  processes. 
Previous  to  that  time  he  had  been  sane.  Such  a  condition  naturally 
could  result  ordy  from  some  severe  psychical  shock  or  acute  brain  dis- 
ease leading  to  profound  mental  disorganization,  yet,  although  apparently 
so  demented,  he  showed  himself  capable  of  various  acts  requiring  consid- 
erable mental  power.  When  given  a  written  order  to  perform  certain 
acts  he  responded  by  writing  various  letters  in  a  disconnected  manner. 
He  had  apparently  lost  all  idea  of  the  movements  for  feeding  himself,  yet 
he  acquired  them  at  once  when  shoAvn  how  to  eat.  Unlike  a  dement,  he 
became  violent  when  deprived  of  food.  Another  patient,  who  feigned 
acute  hallucinatory  confusional  insanity,  was  apparently  ana?sthetic  to  a 
X3in-prick  when  he  knew  what  was  being  done,  but  responded  when  he 
was  unexpected^  pricked.  His  delirium  was  not  continuous,  but  he  was 
forced  to  break  off  until  he  could  think  of  new  material  for  his  delirium, 
and  fill  the  interval  by  singing  a  song  or  repeating  some  stereotyped 
phrase,  and  when  the  symptoms  which  he  at  first  presented  failed  to  win 
confidence  other  symptoms  were  added. 

The  simulator,  moreover,  may  assume  certain  symptoms  which  are 
suggested  to  him.  A  shrewd  feigner  might  naturally  be  upon  his  guard 
if  the  physician  were  to  make  use  of  the  phrase  wliich  was  once  advised, 
that  if  the  patient  were  insane  he  would  present  such  and  such  symp- 
toms ;  but  he  would  often  be  taken  off  his  guard  if  the  remark  be  made 
that  such  symptoms,  if  present,  would  indicate  a  particular-  type  of  dis- 
ease ;  or  if  careful  in(|uiry  were  made  whether  such  symptoms,  wliicli 
were  characteristic  of  the  disease,  were  present.  Thus,  in  the  case  already 
cited,  reported  by  Tamassia,  the  jDatient  manifested  a  feeling  of  cold  in  the 
ear,  and  a  lively  pain  on  prei^sure  over  the  left  clavicle,  on  overhearing  the 
remark  that  in  the  type  of  disease  which  she  exhibited  those  symptoms 
were  always  pi-esent ;  later,  after  another  suggestion,  pressure  over  the 
third  cervical  vertebra  caused  extension  of  the  great  toe.  Simulators 
often  manifest  a  loss  of  memory,  which  is  so  great  as  to  render  it  practically 
impossible  that  it  should  he  real.  As  a  rule,  if  an  insane  person  can  be 
made  to  respond  to  any  questions  he  retains  some  memory  of  familiar 


FEIGNED   DISEASES   OF  THE  MIND  AXD  NERVOUS  SYSTEM.     413 

facts  ;  but  a  simulator  whose  case  was  reported  by  'Bernardini  and  Petraz- 
zani  {Rivista  sper.  ill  freniatria,  vol.  xix.,  p.  GOG)  could  uot  remember  his 
own  name  or  that  of  his  father,  did  not  know  in  what  town  he  was,  was 
ignorant  of  the  motives  for  which  lie  was  arrested,  and  did  not  recognize 
persons  seen  a  moment  before.  One  of  Fritsch's  patients  stated  that 
there  were  six  months  in  the  year  and  three  days  in  the  week,  that 
four  and  five  inade  six,  and  tliat  three  times  foiu'  were  five.  Another 
patient  when  asked  to  mention  the  names  of  the  days  of  the  week  left 
out  Tuesday.  Wlieu  the  insane  answer  questions  at  all  they  usually 
answer  with  some  degree  of  sense.  Thus,  if  an  insane  person  be  asked 
his  age,  he  may  not  give  a  correct  answer,  but  his  answer  will  always 
have  some  definite  relation  to  the  question  put,  and  not  be  sometliing 
entirely  differeut.  He  will  never  say,  as  did  Derozier  (Sj^itzka,  Insiuiity, 
p.  355),  "245  francs,  35  centimes,  124  carriages  to  carry  it." 

Spitzka  {op.  cit.,  p.  3o4)  has  mentioned  various  special  signs  which 
justify  suspicion  of  simulation.  The  simulator  will  demonstratively 
avoid  looking  the  physician  in  the  face,  which  the  patient  in  stuporous 
conditions  never  does.  He  will  give  extravagant,  absurd  answers  to 
simple  questions ;  he  will  often  be  very  slow  in  answering  and  yet  not 
present  the  appearances  of  depressed  states.  He  will  be  watchful  to  see 
whether  au  observer  is  approaching.  He  may  recollect  his  acts  and  ex- 
pressions during  a  feigned  epileptic  state ;  he  may  make  various  strange, 
rhji:limical  movements  which  have  no  analogy  with  any  form  of  insanity ; 
he  TLVAj  complain  more  of  strange  feelings  and  pain  in  the  head  than  the 
insane  usually  do.  He  may,  if  he  be  clumsy,  state  that  he  has  delusions, 
whereas  an  insane  person  who  really  has  delusions  always  states  them 
as  absolute  facts.  It  is,  moreover,  suspicious  if  the  insanity  appear  im- 
mediately after  a  crime. 

Norman  {Bidionary  of  Psychological  Medicine,  vol.  i.,  p.  504)  thinks 
that  paranoia  is  very  commonly  feigned,  but  the  reported  cases  of  feign- 
ing of  paranoia  are  certainly  very  few,  and  to  one  familiar  with  the 
workings  of  the  paranoiac  mind  the  detection  of  smiulation  becomes  easy. 
Few  simulators  could  ever  feign  the  logical  reasoning  of  the  paranoiac 
on  the  subject  of  his  delusions,  his  facial  expression  and  actions.  His 
delusions  are  higlily  systematized  and  worked  into  every  act  and  thought 
of  his  daily  life,  aud  traces  of  them  may  be  found  in  hundreds  of  trivial 
matters.  The  shrewdness  and  logical  reasoning  by  which  every  event 
of  the  day  is  brought  into  train  with  the  general  ideas  of  persecution  is 
something  that  no  one  is  able  to  counterfeit  without  unusual  opportu- 
nities for  study.  In  paranoia,  too,  there  will  be  the  history  of  a  bad  he- 
redity or  of  mental  peculiarities  beginning  in  early  life  and  of  a  gradual 
development  of  the  symptoms. 

The  feigning  of  other  forms  of  insanity  is  distinctly  less  common. 
Paretic  dementia  in  its  advanced  stages  presents  certain  well-known 
physical  signs  of  the  disorder,  so  that  it  cannot  be  shnulated  ;  but  Fiirst- 
ner  {art.  cit.)  has  reported  one  case  of  a  man  wlio  had  formerly  sjient 
several  weeks  with  a  paralytic,  Avho  feigned  the  dementia,  the  dehisions 
of  grandeur,  the  speech,  the  uncleanliness,  aud  even  the  attacks.  Spitzka 
{op.  cit.,  p.  354)  has  cited  the  case  of  a  man  who  feigned.  Avith  consider- 
able skill,  the  prodromal  sjonptoms,  and  Xornian  {art.  cit.)  has  mentioned 
another  case. 

Fiii'stner  {art.  cit.)  states  that  most  frequently  the  simulator  presents 


414  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

the  pictiu'e  of  dementia,  ^vitli  coexisting  apatliY  or  mutism,  or  Tvitli  strik- 
ing contradictions  of  speech,  Tri'iting,  and  actions.  Next  in  fi'eqnency 
comes  a  condition  of  clouding  or  loss  of  consciousness,  which  is  claimed 
to  have  occurred  at  the  time  of  the  criminal  act  and  is  usually  accom- 
panied with  hallucinations.  In  the  thii-d  group  the  s^Taptoms  are  vaii- 
able,  irregular,  and  confused.  The  foui-th  group  presents  conditions  of 
excitement,  with  confused,  senseless  utterances,  and  a  tendency  to  ^dolent 
acts.  All  these  forms,  however,  present  sjTnptoms  not  unlike  those  seen 
in  acute  hallucinatory  confusional  insanity  {Acute  liallucinaiorisclie  Ver- 
iviyrtJieif,  Amentia  of  Meynert),  the  form  of  insanity  which  prohably  is 
the  least  readily  recognized  by  ahenists  in  this  countiy.  In  this  form 
of  insanity  the  simulator  usually  misses  the  pecuhar  confused  condi- 
tion. He  is  too  incoherent,  and  does  not  manifest  the  occasional  intelli- 
gent association  of  ideas  seen  in  these  confused  states;  he  does  not 
give  the  sensible  answers  wliich  patients  can  sometimes  be  roused  into 
gi^dng.  Such  j)atients,  moreover,  will  often  manifest  sense  enough  to 
answer  in  regard  to  familiar  matters  of  life,  to  tell  theii'  name,  to  re- 
member people,  to  state  the  days  of  the  week,  to  count,  or  to  do  simple 
sums.  Most  cases  of  this  condition,  too,  show  distinct  physical  changes, 
a  sluggish  ch'culation,  cold  and  congested  extremities,  and  a  marked  loss 
of  weight ;  they  also  show  occasional  ^dolent  outbiu^sts  and  distinct  de- 
lusions. 

In  all  the  acute  psychoses  there  are  usually  distinct  physical  conditions 
coexisting  with  the  mental  disease  which  point  definitely  to  a  morbid 
state,  such  as  the  increased  pulse,  insomnia,  loss  of  appetite,  loss  in  weight, 
defective  cii'culation,  and  various  conditions  of  the  skin,  especially  cold- 
ness and  cyanosis.  The  simulator  will  sometimes  cease  his  actions  if  he 
tliinks  himself  unobserved.  A  simulator  at  Charlestown  was  extremely 
noisy  when  anybody  was  about,  but  he  was  very  quiet  when  he  supposed 
the  officers  were  out  of  hearing. 

Occasionally  the  simulator  will  not  go  far  enough.  In  a  case  of  in- 
sanity simulated  by  a  young  woman  at  the  Suffolk  County  House  of 
Correction,  communicated  to  me  by  Dr.  Fisher,  conditions  of  dementia 
and  mania  were  feigned.  The  patient  finally  became  extremely  noisy 
and  demonstrative,  and  tore  all  her  clothing  to  pieces,  and  was  found  in 
her  cell  stark  naked ;  yet,  when  the  officers  came  to  the  cell,  she  tuimed 
her  back  to  them,  which  no  maniac  as  ^•iolent  as  that  would  have  done. 

In  rare  cases,  especially  where  the  simulator  has  had  opportunities 
for  studjdng  or  observing  insanity,  tlie  skill  in  feigning  is  sometimes 
extremely  great,  and  shows  wonderful  powers  of  endiu-ance.  A  simu- 
lator at  the  Suffolk  County  House  of  Correction  went  so  far  as  to  daub 
himself  and  his  cell  "with  excrement,  and  finally  to  eat  his  own  fa?ces. 

In  regard  to  the  feigning  of  the  different  t}^3es  of  insanity  the  forms 
which  can  be  most  successfuUy  feigned  are  those  which  present  the  t^'pe 
of  apathy  and  dementia.  Snell  {art.  cit.)  claims  that  if  a  person  can 
remain  absolutely  mute  it  becomes  exceedingly  difficult  to  unmask  his 
feigning.  Field  {art.  cit.)  has  reported  such  a  case,  where  a  man  for 
weeks  would  not  utter  a  word.  Careful  observation  failed  to  show  that 
he  moved  during  the  night,  and  in  passing  through  a  low  doorway  he 
would  strike  his  head  unless  the  attendants  took  pains  to  push  the  head 
down  low  enough  for  him  to  go  under.  In  this  way  he  received  several 
pretty  severe  blows.     He  would  not  take  food,  even  if  it  were  left  beside 


FEIGNED   DISEASES   OF  THE  2IIND  AND  NERVOUS  SYSTEM.     415 

liim,  altliougli  lie  would  swallow  wlien  food  was  put  into  liis  mouth.  He 
did,  liovvever,  respond  when  cold  water  was  sprinkled  upon  him  unex- 
l)e<'ted]y,  and  he  finally  es(;aped  from  the  prison.  One  of  his  fellow-pi-is- 
oners  afterward  eonfessed  that  the  man  talked  with  him,  and  occasionally 
moved  about  when  he  knew  no  one  was  near. 

It  may  be  possible  to  simulate  the  slight  excitement  of  simple 
mania  or  the  slight  depression  of  simple  melancholia,  or  convalescence 
from  these  conditions,  with  a  certain  amount  of  success ;  but  no  patient 
has  the  i)hysical  endurance  to  feign  the  excitement  and  violent  actions  of 
ordinary  mania,  and  although  he  can  assume  incoherence  for  a  time,  he 
cannot  keep  up  the  incessant  flow  of  incoherent  plirases ;  after  a  time 
nature  must  assert  itself  and  fatigue  ^^dll  be  manifested.  Insomnia, 
rapid  loss  of  weight,  and  loss  of  appetite,  are  aU  beyond  his  control.  The 
same  may  be  said  of  the  feigning  of  acute  melancholia.  Although  for 
a  time  he  may  assume  the  depression,  he  cannot  keep  up  the  psychical 
anaesthesia,  the  profound  depression,  the  manifestations  of  gi'ief,  the  self- 
absorption  ;  nor  can  he  feign  the  insomnia,  the  cold  and  clammy  extrem- 
ities, the  weak  ]3ulse,  the  loss  of  appetite,  the  constipation,  and  the  various 
other  physical  symptoms  so  often  seen. 

In  conclusion,  it  may  be  said  that  in  the  majority  of  cases  where  simu- 
lation is  suspected  there  may  be  sjrmptoms  present  upon  examination 
which  will  prove  that  our  suspicions  are  in  part  groundless ;  but  it  must 
also  be  borne  in  mind  that  the  failui*e  to  find  such  symptoms  as  have 
already  been  described,  or  even  the  detection  of  sjonptoms  which  are 
apparently  contradictory,  is  not  absolute  proof  that  the  disorder  is 
simulated. 


BIRTH,  SEX,  PREGNANCY,  AND  DELIVERY. 

BY 

ANDEEW  F.  CUEEIER,   M.D. 
I.    BIRTH, 

Legal  OWgation  of  Physicians  ivith  Reference  to  the  Recording  of  Births 
— JDetermination  of  the  Period  of  Development  in  Xeic-horii  Infants, 
e^speciaUy  in  the  Still-born,  with  Evidence  Relating  to  the  Yiahility  of  the 
Latter. 

The  importance  of  correct  and  accurate  vital  statistics  both  to  the 
lawyer  and  tlie  physician  is  self-e^^dent.  Indeed  it  is  a  matter  in  which 
the  entire  commnnity  is  interested,  for  in  tlie  absence  of  accurate  records 
of  this  character  how  can  the  status  of  a  community  as  to  population 
be  ascertained  f  But  there  are  other  considerations  which  are  of  much 
'greater  significance  in  this  conuection — considerations  which  affect  the 
material  welfare  of  large  luimbers  of  individuals,  and  which  depend  in  no 
small  degree  upon  the  faithfulness  with  which  these  records  are  made. 
The  responsibility  of  physicians  is,  therefore,  direct  and  decided  in  this 
matter,  and  should  be  appreciated  from  the  very  beginniug  of  their  career. 
The  state  rather  than  the  church  shoidd  be  the  custodian  of  such  records, 
at  any  rate  in  so  far  as  the  material  interests  of  the  individual  ai-e  con- 
cerned. The  recognition  of  this  fact  has  doubtless  been  ai)  important 
factor  in  the  formation  and  development  of  bureaus  of  vital  statistics  in 
connection  with  the  systematic  regulation  of  all  matters  which  pertain  to 
the  public  hygiene.  One  of  the  decided  evidences  of  ad\^ancino-  civili- 
zation consists  in  the  very  general  establishment  of  boards  of  health,  and 
the  development  of  sanitary  science  in  all  parts  of  the  world.  "With  in- 
creasing experience  the  work  of  such  bodies  is  yearly  becoming  more 
perfect  and  valuable.  It  will  continue  in  this  direction,  pari  passu,  with 
the  importance  which  physicians  attach  to  it.  and  the  heartiness  and  iu- 
telhgence  of  then-  cooperation.  In  New  York  the  law  requii-es  the  return 
of  a  birth-certificate  to  the  local  board  of  health  or  other  offieial  keeper 
of  records  within  ten  days  after  the  birth  of  every  child,  whether  alive  or 
dead  at  birth  ;  and  a  penalty  of  ten  dollars  attaches  to  neglect  to  fulfiU  this 
requirement.  This  is  the  duty  of  the  physician  if  he  were  in  attendance 
at  a  given  birth ;  otherwise  the  return  must  be  nuide  by  the  midwife  or 
other  person  who  assisted  when  the  birth  took  place.  The  im]iortauce  of 
this  subject  should  be  emphasized  bv  those  who  serve  as  instructors  in 

417 


418  ^   SYSTEM  OF  LEGAL  MEDICLNE. 

medical  colleges,  and  in  the  examinations  whicli  candidates  for  license 
to  practice  are  compelled  to  pass. 

In  France  the  following  sections  from  the  Civil  Code  appertain  to  the 
registry  of  bii'ths : 

"  Art.  55.  Declarations  of  birth  mnst  be  made  within  three  days  of 
accouchement  to  the  proper  civil  of&cer ;  the  child  shall  be  shown  to  him. 

"  Art.  56.  The  bii-th  of  a  child  shall  be  declared  by  its  father,  or,  in 
default  of  the  father,  b}^  the  physician,  surgeon,  midwife,  officer  of  health, 
or  other  person  who  assisted  at  the  accouchement,  and  if  the  mother  were 
confined  away  from  her  own  home  by  the  person  at  whose  house  she  wa& 
delivered.  The  fact  of  the  bii'th  shall  be  stated  in  proper  legal  form  in 
the  presence  of  two  witnesses. 

"  Art.  57.  The  return  of  a  birth  shall  specify  the  day,  hour,  and  place 
of  birth,  the  sex  of  the  child  and  the  names  he  has  received,  the  fii'st  and 
second  names,  occupation,  and  residence  of  the  father,  mother,  and  wit- 
nesses." 

"  Penal  Code,  Art,  34:6.  Every  person  assisting  at  an  accouchement 
who  shall  fail  to  make  the  declaration  as  prescribed  in  ^t.  56  of  the 
Civil  Code  and  in  Art.  55  of  the  same  Code  shall  be  punished  by  impris- 
onment of  from  six  days  to  six  months  and  by  a  fine  of  from  16  to  300 
francs." 

The  father  or  head  of  the  house  must  report  the  birth  if  present  at 
the  time ;  otherwise  upon  the  physician,  if  one  were  present,  devolves 
this  obligation,  if  he  assisted  efficiently  in  the  accouchement.  The  duty 
devolves  upon  him  though  the  child  is  born  upon  his  arrival,  if  it  is  still 
united  by  the  cord  to  its  mother  and  the  placenta  is  still  in  utero  or  in 
vagina.  The  same  obligation  holds  for  still-born  infants  if  they  have 
passed  the  fourth  month  of  fetal  life.  (Vibert,  Precis  de  Medecine  Legale, 
Paris,  1886,  p.  645.)  The  determination  of  the  period  of  development 
which  has  been  reached  by  a  new-born  infant,  whether  it  is  matiu-e  or 
premature,  whether  it  was  living  and  viable  at  birth,  are  all  matters  of 
the  greatest  importance,  and  can  usually  be  decided  mth  a  considerable 
degree  of  precision.  These  subjects  are  elaborated  in  the  article  upon 
Infanticide  (q.v.). 

n.  SEX. 

Hermaphrodism — Defective  and  Rudlmentcn'i/  Organs  of  the  Genital  Ap- 
paratus, and  the  Bearing  of  the  same  upon  Matrimony  and  Fertilitif 
— Determination  of  Sex — Pntertij  and  its  Attendant  Phenomena — ■ 
Menstruation,  Normal  and  Abnormal — The  Menopause, 

Hermaphrodism  or  hermaphroditism  is  a  condition  which  has  elicited 
a  great  deal  of  attention  from  the  earliest  times  and  has  given  rise  to  a 
great  variety  of  opinions  and  speculation.  The  work  of  Klebs  upon  this 
subject  is  scholar!}'-  and  rational,  but  that  of  Pozzi  in  his  Traite  de  Gyne- 
cologie,  vol.  ii.,  p.  1069,  is  more  recent,  and  will  be  frequently  referred  to 
in  this  article.  To  go  to  the  root  of  the  matter  in  defining  the  term,  we 
mnst  have  in  a  true  hermaphrodite,  as  Pozzi  correctly  states,  a  being  who 
has  the  genital  organs  of  both  sexes,  with  the  possibiHty  of  functional 
activity  of  both  sets  of  organs.  The  testicles  and  ovaries  are  the  essen- 
tial organs  of  reproduction  in  the  male  and  female  sexes  respectively. 


liiJiTH,  >sjcx,  rRijaxAycY,  and  delivery.  a\\) 

A  true  Iic'i'iiuiplirodite  must  have  orji^ans  with  the  aimtoiuu^al  i)e(Miliai-i- 
ties  of  botli  ovaries  and  testicles.  Pozzi  deehires  that  there  does  not 
exist  a  single  incontestable  example  in  which  this  condition  has  been 
realized;  but  lie,  as  well  as  Klebs,  has  evidently  overlooked  the  case  of 
Heppner  (quoted  by  Garrigiies  in  Mann's  iSt/.sfein  of  Gj/Hf'coIof/i/,  vol.  i.,  j). 
2G9),  which  w.is  that  of  a  child  which  died  at  the  age  of  two  months  and 
was  fonud  by  post-mortem  exanunatiou  to  have  a  hyi)ospadiac  penis  or 
enlarged  clitoris,  a  cleft  scrotum,  a  sinus  urogenitalis  and  Kosenniiilici-'s 
organ  representing  parovarium  and  epididymis,  a  prostate  gland,  lioth 
testicles,  vagina,  uterus,  Fallo})ian  tubes,  both  ovaries,  I'ound  and  1)road 
ligaments.  The  ovaries  contained  Gi-aafian  follicles  with  ova,  and  the 
testicles  had  seminal  canals.  Among  plants  and  many  of  the  lower 
orders  of  invertebrate  animals  the  condition  of  true  hermaphrodism  is 
common  enough.  Bland  Sutton  states  {Tra»s<ictions  London  I'atJioJofjinil 
/Socicfi/,  TS85,  pp.  509,  510)  that  among  the  vertebrates  it  occurs  in  the 
cod  and  herring,  and  that  an  ovo-testis  is  very  common  in  the  toad  and 
frog.  Hermaphrodism  is  usmilly  classitied  as  true  and  spurious,  the 
former  of  which  must  be  exceedingly  rare,  making  due  allowance  for 
any  cases  which  may  not  have  been  reported.  Pozzi  has  examined  many 
specimens  which  have  been  i-egarded  as  examples  of  hermaphrodism  in 
the  Musee  Dupuytreu  and  elsewhere,  as  well  as  the  available  literature, 
and  has  found  them  all  spurious.* 

Instead  of  true  and  spurious  hermaphrodites  it  would  seem  more 
2)ractical  to  foUow  Pozzi  in  classifying  them  as  (j>/ua)i(h'fs  and  (nidrof/i/ns,. 
according  as  the  peculiarities  of  the  female  or  the  male  sex  predominate. 
In  gyiMndei's  there  may  be  menstruation,  Avell-developed  manima^,  uterus 
and  ovaries,  aud  the  possibility  of  impregnation.  In  (i)idro(j>fns  menstru- 
ation is  absent,  the  breasts  ai;e  of  the  male  type,  uterus  and  ovaries  are 
absent,  and  there  is  a  possibility  that  they  ma}^  beget  offspring.     In  both 

*  Plenty  of  cases  ai'e  recorded  in  legal  and  medical  literature  as  veritable  instances 
of  liermai)lirodism.  Lukomsky's  case  (quoted  by  R.  Guiteras  in  Morrow's  >'<i/stciii  of 
Genito-iirinarii  Diseases,  Si/plriloln;/!/,  and  Derniatolofiy,  vol.  i.,  p.  50)  was  that  of  an 
individual  thirty  years  of  age,  with  penis  two  inches  long,  without  uretlu'a,  below 
which  was  a  scrotum  with  two  testicles.  Below  the  scrotum  was  a  normal  vulva, 
with  labia  majora,  labia  minora,  and  clitoris,  the  urethral  opening  being  below  the 
clitoris.  The  viigina  was  three  inches  in  depth  and  terminatcnl  in  a  normal  uterus. 
The  patient  had  never  menstruated.  When  coitus  was  practiced  Avith  a  female  a 
whitish  tlind  was  ejected  through  the  vaginal  slit.  Whether  ovaries  were  present  is 
not  known  ;  hence  the  evidence  is  inconclusive. 

Wluirton  and  Btillo  {Medical  Jiirisiinidciicc,  1884,  vol.  iii.,  ji.  140)  narrate  several 
cases  of  varying  degrees  of  importance  and  authenticity,  including  the  following : 
Kiwiseh's  case  was  thirty-three  years  of  age,  had  a  normal  penis,  with  rugose  but 
empty  scrotum,  a  normal  uterus  in  proper  position,  a  rudimentary  vagina  opening 
into  the  prostatic  portion  of  the  urethra,  Fallopian  tubes,  tliree  and  tln'ee-(juai1er 
inches  long,  with  imperfect  fimbria\  normal  round  ligainents,  no  ovaries,  testicles 
with  epididymis  and  efferent  duct  leading  to  the  inguinal  ring  and  finally  opening- 
into  the  prostate  gland,  the  latter  being  of  normal  size  and  provided  with  vesicular 
seminales  on  either  side. 

Ackley  and  Blackman's  case  was  twenty-six  years  of  age,  with  the  general  appear- 
ance of  a  man,  but  witii  very  broad  hips.  Painful  discharge  of  blood  had  occurred 
from  the  penis  at  monthly  intervals.  There  was  a  large  penis,  also  an  empty  fcrotum. 
])ervious  Fallopian  tubes,  ovaries,  testicle  on  each  side  above  the  ovary,  with  excr<'- 
tory  ducts  leading  from  tliem,  vagina  opeiiing  into  the  neck  of  the  bladder,  and  ])ros- 
fate  gland.  The  inner  surface  of  the  vaginn  was  covered  with  blood  wheTi  examined 
l>ost  mortem.  The  same  s])ecinien  was  examined  by  J.  B.  8.  Jackson,  wlio  found  no 
trace  of  the  os  externum  uteri,  no  vaginal  portion  of  the  cervix  uteri,  and  a  vagina  only 


420  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

varieties  tlie  individual  may  act  as  the  male  or  female  agent  in  copnla- 
tion,  and  it  may  be  impossible  to  determine  tbe  sex  without  abdominal 
operation  or  post-mortem  examination.     In  gijnanders  the  cHtoris  may 

be  so  much  enlarged  as  to  serve 


^\- 


the  fmietional  pui-pose  of  the 
penis;  in  androgt/ns  the  penis 
may  be  very  smaU,  the  scrotum 
bihd,  and  the  opening  of  the  ure- 
thra so  large  as  to  admit  the  penis 
in  the  copulative  act.  The  ac- 
compaupng  figiu-es  from  Pozzi's 
work  show  the  difficulties  which 
~^^  -  t      ,  --•    may  be  encountered  in  attempt- 

ing to  determine  the  sex  in  such 
cases. 

Hermaphrodites,  of  which- 
ever variety,  are  probaldy  al)le  to 
beget  and  bear  offspring,  at  least 


Fig.   60.— c.   Clitoris:  h,   connecting  bridge   from  Fig.  61.— e.  Clitoris;  or,  orifieium 

clitori.-i  to  meatus  tirinarius ;  mu,  meatus  urinaritis ;  or,       vaginee.     (Pozzi. ) 
oriflcium  vaginae.    (Pozzi.) 

in  some  cases,  but  the  common  observation  is  that  they  are  sterile ;  in 
fact  but  two  cases  occur  to  the  wiiter  in  the  literatm-e  of  the  subject  in 

four  or  five  lines  in  eii-cumference.  Xo  true  ovarian  stmetui'e  was  found.  The  testi- 
cles -were  normal  in  size  and  structure,  but  there  -v^-ere  no  vasa  deferentia,  vesiculis 
seminales,  or  prostate  gland. 

Among  recently  reported  cases  may  be  mentioned  one  of  Mr.  Edgar  "Willett's, 
reported  at  the  meeting  of  the  London  Pathological  Society,  February  6,  1894.  The 
specimens  presented  -were  from  a  man  who  died,  at  the  age  of  forty-foiu-,  of  cerebral 
hemorrhage.  The  testicles  were  undescended ;  there  was  a  well-developed  uterus  and 
vagina ;  the  sexual  glands,  though  occupying  the  situation  of  the  ovaries,  proved  on 
microscopical  examination  to  be  the  testicles,  the  membrana  propria  of  the  tubuli 
being  very  thick.  There  was  a  tunica  vaginalis  on  either  side  of  the  scrotum,  and 
the  penis"  was  well  developed.  The  man  wore  a  beard,  was  married,  and  had  two 
children.  The  testicles  were  pro^-ided  with  vasa  deferentia.  which  passed  down  by 
the  side  of  the  vagina  toward  the  prostatic  di^•ision  of  the  urethra.  The  vagina  nar- 
rowed as  it  perforated  the  prostate  gland,  and  opened  in  the  usual  sittiation  of  the 
uterus  maseulinus.  A  closed  Fallopian  tube  proceeded  from  the  uterus  on  either 
side,  terminating  above  the  globus  major  of  the  epididraiis  in  a  body  representing  the 
nsual  hydatid  of  Morgagni.  'Mx.  Stonham  reported  a  similar  case  to  the  society  a 
few  years  ago. 


BIRTH,  SEX,  PREGNANCY,  AND   DELIVERY.  421 

wliieli  tliey  were  observed  to  be  fertile.  (Cases  are  reported  in  which 
lierinaphrodites  have  discharged  semeu  containing'  living  sjjerinatozoa, 
while  others  have  had  ovaries  in  which  were  Crraaiian  follicles  and  ova.) 
They  must  necessarily  hold  a  peculiar  position  before  the  law.  Their  right 
of  holding  property  and  voting  might  be  called  in  question.  If  the}^  mar- 
ried the  marriage  might  be  annulled  on  account  of  their  i^hysical  defects, 
and  yet  the  law  does  not  f  orl)id  their  man-ying.  They  may  have  inordinate 
or  defective  sexual  desire.  In  the  cases  which  one  finds  recorded,  those  wlio 
resemble  females  are  in  some  instances  excessively  libidinous.  This  may 
be  due  to  the  exul)erance  of  erectile  tissue  in  the  preteruaturally  enlarged 
clitoris,  and  the  irritation  to  which  that  sensitive  organ  is  continually 
exposed.  In  those  who  resemble  males,  on  the  other  hand,  an  aversion 
to  women  and  to  the  sexual  act  is  sometimes  reported.  The  absence  of 
well-marked  peculiarities  which  are  common  in  the  physical  development 
•of  well-formed  specimens  of  either  sex  is  to  be  expected  in  individuals  of 
such  doubtful  or  bleuded  sex  as  are  hermaphrodites,  but  one  does  not 
see,  in  actual  exj^erience,  the  grotesque  characteristics  viith  which  -smters 
have  been  prone  to  clothe  these  unfortunates.  One  should  not  expect 
to  find,  on  the  one  hand,  a  strong  voice  and  a  manly  beard,  or,  on  the 
other,  well-rounded  limbs  and  womaidy  breasts — these  are  the  attributes 
of  persons  who  are  not  physically  defective;  but  one  may  sometimes  see 
individuals  with  imperfect  generative  organs  of  one  sex  and  well-marked 
peculiarities  of  figure  and  habit  of  the  other.  The  precise  determination 
of  the  sex  in  such  cases  is  not  easy.  Hermaphrodites  are  not  the  onty 
ones  who  possess  peculiarities  of  the  genital  organs,  but  such  j^ecidiari- 
ties  are  often  their  chief  distinguishing  feature,  and  the,y  will  now  be 
considered  in  detail,  together  mth  similar  or  related  peculiarities  in 
individuals  al)out  whom  the  sex  is  not  doubtful. 

The  genital  organs  of  the  male  are  the  penis  and  scrotum  externally, 
the  latter  containing  the  testicles  with  their  appendages,  the  epididy- 
mides, and  the  spermatic  cords,  which  connect  the  testicles  with  the 
.seminal  vesicles,  the  latter  lying  at  the  base  of  the  bladder  and  serving 
as  reservoirs  for  the  semen.  This  fluid  is  conveyed  from  the  testicles, 
where  it  is  secreted,  through  the  vas  deferens,  a  tube  contained  in  the 
spermatic  cord,  to  the  seminal  vesicle,  whence  it  is  discharged  in  the  act 
■of  copulation  into  a  short  tnhe  called  the  ejacidatory  duet,  and  thence 
into  the  urethra,  the  canal  which  extends  through  the  entire  length  of 
the  penis,  terminating  in  the  bladder,  the  reservoir  of  the  urine.  The 
penis  is  joined  to  the  bladder  by  a  trilobate  structure  called  the  prostate 
gland,  through  which  the  urethra  passes,  terminating  in  the  bladder. 
The  minute  anatomy  of  these  structures  is  not  essential  in  this  connec- 
tion. The  testicles  are  developed  in  the  early  months  of  fetal  life  on 
either  side  of  the  lower  (lumbar)  segment  of  the  spinal  column,  from 
which  position  they  gradually  descend  into  the  pelvis  or  bony  basin 
which  connects  the  body  or  trunk  with  the  lower  limbs.  During  the 
seventh  month  each  testicle  leaves  the  pelvis,  passing  do"\vn  a  canal  in 
the  anterior  and  lowermost  portion  of  the  al^domen  kno^^Ti  as  the  in- 
giiinal  canal,  and  by  the  end  of  the  eighth  month  it  has  reached  its  final 
destination  in  the  scrotum. 

In  the  female  the  external  structures  are  the  mons  Veneris,  which  is 
composed  mainly  of  fat,  with  its  appropriate  external  coverings  (skin  and 
liair),  and  the  labia  majora,  the  latter  presenting  an  elliptical  appeal'- 


422 


A   SYSTEM  OF  LEGAL   MEDICINE. 


ance,  tying  imder  tlie  mons  Veneris  and  being  partly  concealed  from 
view  on  account  of  tlie  inclination  of  tlie  pelvis  when  a  woman  is  in  the 
erect  position.  Within  the  depression  at  the  inner  aspect  of  the  labia 
majora  and  including  its  upper  two  thirds  are  the  labia  minora  or 
nymphse,  and  at  their  apex  is  the  clitoris.     Below  the  clitoris  is  the 

opening  of  the  ni*ethra,  the  lat- 
ter terminating  in  the  bladder^ 
and  below  this  opening  the 
entrance  or  introitus  of  the  va- 
gina, which  in  the  vii'gin  is  usu- 
ally shielded  by  a  membranous 
structure,  the  hymen.  The  va- 
gina is  a  tube  about  three  inches 
long  which  terminates  in  the 
uterus  or  womb,  a  portion  of  its 
necli  being  within  the  vagina, 
while  the  remainder  of  the  necTi 
and  the  entire  hody  are  above 
the  vagina  and  in  the  cavity  of 
the  pelvis.  The  uterus  is  pear- 
shaped,  and  from  each  upper 
corner  or  horn  extends  a  cylin- 
drical tube  three  and  a  half 
inches  long,  the  Fallopian  tube,, 
terminating  in  a  beautifully 
fringed  extremity.  Below  each 
tube,  and  attached  to  its  inner 
or  uterine  end  by  a  ligament  an 
inch  or  an  inch  and  a  half  long, 
is  the  ovary,  an  ovoid  strncture 
about  as  large  normally  as  a 
small  English  walnut.  It  is  also 
attached  to  the  fringed  extrem- 
ity of  the  tube  by  a  single  stalk 
or  pedicle  of  very  delicate  struc- 
ture. As  an  ovum  matures  in 
the  ovary,  its  envelope,  the 
Graafian  follicle,  swells,  and, 
when  it  ruptures,  the  ovum  is 
grasped  by  the  fringe  or  ten- 
tacles of  the  tube,  like  the  ten- 
tacles of  a  sea-polyp,  and  car- 
ried forward  into  and  along  the 
tube,  the  cilia  of  the  epithelium 
with  which  the  tube  is  lined 
pushing  it  along  until  it  reaches 
the  uterus.  On  its  way  through  the  tube  or  within  the  uterus  it  is  met 
by  the  spermatozoon,  union  of  the  two  elements  and  conception  taking 
place ;  or  if  this  does  not  occur  the  ovum  is  cast  out  of  the  uterus  as  inert 
matter. 

The  penis  may  be  abnormally  large  or  abnormally  small.     It  may  be 
so  smaU  as  to  simulate  an  enlarged  clitoris  and  perhaps  cause  uncertainty 


■^ 


^■A: 


^' 


I 


Fig.  63.— Example  of  hermaphrodism.    (Pozzi.) 
c,  Clitoris. 


r.lRTII,  SEX,  ritEGNANCY,  AND    DELIVEUY. 


423 


as  to  the  sex  of  the  iiulivithial.  If  the  or^-un  in  question  has  a  canal  and 
this  canal  terniiiiates  in  tlie  bladder,  the  or^uii  niust  he  a  penis  and  tlio 
individual  a  male,  no  matter  what  other  defects  may  exist.  An  imper- 
fect urethra  with  an  opening  on  the  lower  surface  of  the  penis  (hypo- 


Fig.  63.— p,  Hypospadic  penis;  s,  symphysis  pubis;  t,  testicle;  i\  bladder;  v.p,  pseudovagina; 

7',  rectum. 


spadias),  or  on  the  upper  surface  (epispadias),  or  on  the  skin  (perineum) 
between  the  scrotum  and  the  anus,  is  a  common  deformity  in  hermaph- 
rodites and  in  some  in  whom  there  is  no  doubt  in  regard  to  sex.  Such 
a  deformity  often  prevents  fruitful  sexual  intercourse.  Absence  of  the 
penis  may  result  from  disease  or  injury ;  congenital  absence  of  the  organ 
is  of  very  rare  occurrence.  The  scrotum  may  be  cleft  or  bifid,  suggesting 
the  labia  majora  of  the  female,  and  this  is  common  in  hermaphrodites. 
It  may  be  empty,  that  is,  without  testicles,  or  it  may  have  a  single  testi- 
cle, neither  of  them,  or  only  one,  having  descended  during  fetal  life.  It 
may  have  a  smooth  surface  like  the  lal)ia  majora,  or  the  wrinkles  and 
creases  which  are  normal  to  it.  The  development  of  the  testicles  may 
have  been  arrested,  or  they  may  have  withered  (atrophied)  and  disap- 
peared. If  the  testicles  have  descended  only  partially  they  may  be 
fomid  thus  dislocated  post  mortem,  and  gi^"e  rise  to  uncertainty  as  to 
whether  they  are  ovaries  or  testicles.  Absence  of  the  testicles  may  be 
due  to  disease  or  injury.  In  eunuchs  the  testicles  alone  may  have  been 
removed,  or  the  testicles  and  penis.  Disease  of  the  other  organs  of  the 
male  gcniito-urinary  apparatus  may  have  an  important  bearing  upon  the 
question  of  i)rocreative  power  and  sexual  capacity,  though  it  might  not 
cause  difficulty  in  the  detin-mination  of  sex. 

In  the  feiiiale  the  appi^arance  of  the  labia  majora  might  suggest  a 
defective  scrotum,  especially  if  one  or  both  ovaries  had  descended  into 


424 


A   SYSTEM  OF  LEGAL  MEDICINE. 


tliem ;  au  accident  wliicli  has  sometimes  occmTed,  tliougli  in  an  extensive 
experience  during  many  years  the  writer  has  never  seen  it.  The  clitoris 
is  normally  half  an  inch  to  an  inch  in  length,  only  its  minnte  extremity 
being  nsnally  visible,  bnt  it  may  be  enlarged  to  a  length  of  three,  four,, 
or  even  five  inches.  (See  Wharton  and  Stille,  vol.  iii.,  p.  143.)  It  is  sus- 
ceptible of  erection,  and  when  gTcatly  enlarged  may  perform  the  same 
function  as  the  penis  in  the  copulative  act ;  but  it  has  no  canal,  or  if  an 
abnormal  canal  exists  it  does  not  terminate  in  the  bladder.  The  labia 
minora  may  be  small  and  inconspicuous — in  hermaphrodites  they  may  be 
rudimentary — esjDecially  if  the  chtoris  is  greatly  enlarged.  In  adult  life 
they  may  become  large  and  prominent ;  in  the  Hottentots  they  are  enor- 
mously enlarged  and  jjendent.  They  are  often  enlarged  as  the  result  of 
masturbation,  and  sometimes  as  the  result  of  venereal  disease.* 

The  urethra,  normally  of  small  caliber,  and  about  an  inch  long,  is 


Fig.  64.— Author's  case,  representing  enlargement  of  labia  minora. 


*  The  accompanying  figure  represents  a  rare  case  of  this  character  which  has  been- 
Tmder  the  writer's  care.  The  patient  is  a  large,  well-deA'eloped  woman,  twenty-four 
years  of  age,  a  prostitute,  a  syphilitic  for  three  years,  an  opium-smoker  for  a  year. 
The  tumor  has  existed  a  year  and  a  half,  is  painless,  and  does  not  prevent  sexual 
intercourse.  After  endeavoring  ineffectually  to  reduce  its  size  by  means  of  anti- 
syphilitic  drugs  it  was  entirely  removed  with  the  red-hot  cautery-knife. 


BIllTU,  HEX,   ritEGXAXCY,  AND   DELIVERY. 


425 


susceptible  of  considerable  dilatation.  In  henna])lii-odites  and  those  who 
were  otherwise  deformed,  it  has  sometimes  been  mistaken  for  the  vagina 
and  has  been  nsed  in  the  eopidative  act,  of  course  to  the  great  detriment 
of  tlie  individual. 

The  hymen  may  be  rudimentary  and  present  no  obstruction  to  coitus, 
or  ii>  may  be  so  thick  and  firm  that  coitus  will  l)e  impos.si1)le  until  it  has 
been  incised  or  entirely  removed.     In  such  cases  serious  difficulty  may 


Fig.  63.— Figure  representing  tlie  female  organs  of  generation.     (D.  Ber^-y  Hart.) 

F,  Ovarv:  G,  par  ovarium;  Jf,  round  ligament ;  0,  broad  ligament;  N,  entrance  to  vagina; 
J/,  labium  minus;  K,  labium  majus;  M,  clitoris:  P,  vagina;  ^-i,  os  uteri;  J3,  body  of  uterus; 
C,  fundus  uteri;  A  Fallopian  tube;  £,  fimbriated  extremity  of  tube. 


arise  on  account  of  the  retention  of  the  menstrual  fluid.  A  large  ab- 
dominal tumor  may  thus  be  formed,  and  the  issue  may  l)e  a  fatal  one. 
The  vagina  may  be  rudimentary  or  entirely  wanting.*  If  tlie  vagina  is 
imdimentary  it  is  often  possible  that  it  may  be  so  developed  as  to  accom- 
plish all  the  necessary  functional  purposes. 

The  uterus  is  seldom  entirely  wanting.  I.  E.  Taylor  has  reported 
two  cases  in  whicih  x)ost-mortem  examination  revealed  no  trace  of  the 
organ.  It  is  very  frequently  rudimentary.  Peaslee  has  reported  a  case 
in  which  it  was  a  mere  band  of  tissue  of  no  functional  importance. 
(Mann's  Sijstem  of  Gi/nerologi/,  vol.  i.,  p.  269,  quoted  by  Garrigues.)  The 
writer  has  seen  many  cases  in  which  it  was  very  smaU  and  insignificant. 
In  hermaphrodites  it  is  usually  rudimentary.     Such  a  condition  may 

*  An  interesting  case  of  tliis  character  -n-as  imder  the  wi-iter's  care  recently.  The 
patient  was  a  girl,  sixteen  years  old,  with  no  vagina,  all  the  other  organs  being  well 
developed.  Inability  to  discharge  the  menstrual  fluid  had  led  to  tlie  formation  of  a 
large  abdominal  tumor.  Tliis  Avas  opened  and  evacuated  tlirough  the  rectum.  A 
false  opening  was  then  made  where  the  vagina  should  have  been,  but  after  two 
months  her  pliysician  unfortunately  allowed  it  to  close.  The  menstrual  fluid  then 
reaccumnlated,  and  tlie  writer  foimd  it  necessary  to  open  the  abdomen  and  remove 
tlie  ovaries,  thus  bringing  menstruation  to  an  end.  In  view  of  tlie  possiVnlity  of 
matrimony  a  vagina  was  tlien  made  by  cutting,  tearing,  and  dilating,  the  operation 
requiring  several  montlis  for  its  completion.  This  vagina  miglit  serve  the  purpose  of 
copulation,  but  could  not  be  expected  to  answer  for  the  safe  passage  of  a  fetus ;  hence 
the  necessity  of  sterilizing  the  patient  to  anticipate  a  possible  calamity.  The  patient 
was  at  last  accounts  entirely  well. 


426  ^   SYSTEM  OF  LEGAL  MEDICINE. 

effectually  prevent  impreguatiou,  but  it  is  astonisMug  to  "wliat  an  extent 
sucli  an  organ  maj"  be  de^elojjed  by  suitable  gynecological  treatment  or 
by  the  stimulus  of  coitus.  If  impregnation  takes  T)lace  serious  results 
may  oceui*,  on  account  of  the  imperfect  character  of  tlie  tissue ;  either 
abortion  or  ruptiu-e  of  the  organ,  usuall}^  with  fatal  resTilt,  being  the 
consequence.  The  Falloj)ian  tubes  are  essential  organs  in  the  female 
reproductive  apparatus,  forming  the  only  medium  of  communication 
between  the  uterus  and  the  ovaries,  and  unless  they  are  in  proper  func- 
tional and  structural  condition  the  jjassage  of  ova  to  the  uterus  and  the 
accomplishment  of  impregnation  become  impossible.  The  tubes  are  not 
essential  to  menstruation,  as  some  writers  have  affirmed,  for  menstrua- 
tion has  been  kno^^'n  to  continue  after  they  have  been  removed,  more  or 
less  of  the  ovarian  structui*e  having  been  retained.  Then*  importance  as 
■oviducts  is  supreme,  and  for  this  function  there  can  be  no  substitute. 
They  may  be  rudimentary,  mere  imj)ervious  cords,  and  they  are  suscep- 
tible of  various  forms  of  disease  at  all  periods  of  life.  Disease  of  the 
tubes  may  be  cm-able  spontaneousl}'  or  as  the  result  of  siu-gical  treat- 
ment, or  it  may  be  incurable.  It  may  be  of  a  malignant  character  (sar- 
coma, carcinoma),  or  inflammatory,  the  result  of  gonorrhea,  abortion,  or 
labor  at  term ;  it  may  be  due  to  infection  from  unclean  hands  or  instru- 
ments, the  infectious  pro'cess  having  extended  from  the  vagina  or  uterus ; 
or  it  may  be  an  element  in  an  infectious  disease  such  as  tuberculosis  or 
syphilis.  In  the  great  majority  of  cases  the  disease  is  due  to  gonorrhea 
or  abortion,  the  ultimate  cause  being  an  infective  bacterium.  It  is  one 
of  the  most  common  forms  of  disease  peculiar  to  women,  and  its  im- 
23ortance  in  a  medico-legal  sense,  especially  with  reference  to  the  respon- 
sibility of  the  gynecologist  in  its  recognition  and  treatment,  is  gTcat.  It 
has  heretofore  escaped  recognition  in  medico-legal  works,  principally  for 
the  reason  that  until  very  recentty  correct  knowledge  of  the  subject  was 
possessed  hj  yery  few.  In  hermaphrodites  the  Fallopian  tubes  are  often 
wanting  or  rudimentarj' . 

The  ovaries  are  the  distinguisliing  sexual  organs  of  the  female  as  the 
testicles  are  of  the  male,  and  the  absence  of  them  renders  the  individual 
absolutel}'  incapable  of  conception.  The}'  control  the  function  of  o^iila- 
tiou  and  have  a  ver}'  decided  influence  upon  menstruation.  In  cases  in 
which  they  have  been  removed  menstruation  usually  ceases  at  once  or 
within  a  short  time,  but  it  has  been  known  to  continue  for  many  months 
after  their  removal,  thus  supporting  the  statement  of  Aithur  Johnstone 
that  the  menstrual  function  is  controlled  by  a  nerve  in  the  broad  liga- 
ment contiguous  to  the  uterus,  and  that  this  nerve  has  not  been  cut  when 
the  ovaries  are  removed  should  menstruation  persist.  The  ovaries  may 
be  congenitally  absent  or  they  may  be  very  smaU  and  defective  in  struct- 
lu'e.  Like  the  FaUopian  tubes,  they  are  extremely  susceptible  to  dis- 
ease, and  the  disease  may  begin  in  fetal  life  or  it  may  be  deferi'ed  until 
advanced  age.  Tliere  is  perhaps  no  organ  of  the  body  which  is  sulgect 
to  disease  in  a  gi-eater  variety  of  forms,  and  perhaps  none  Avhich  is  at- 
tacked more  frequentty.  It  fm-ther  resembles  disease  6t  the  FaUopian 
tubes  in  that  it  nuiy  be  recovered  from  spontaneously,  it  may  make  the 
patient  an  invalid  for  life,  it  may  be  fatal  -without  a  timely  surgical 
operation,  or  it  may  be  inevitably  fatal  in  spite  of  any  form  of  treat- 
ment. Disease  of  the  ovary  may  be  independent  of  disease  in  any  other 
organ,  or  it  may  be  an  extension  of  disease  in  the  tubes.     It  is  the  gloay 


BIRTH,  SEX,  ritEG NANCY,  AND   DKLllERY.  427 

of  modern  g'ynecological  surgery  that  it  lias  found  a  remedy  for  the 
disease  in  thousands  of  eases  whieli  formerly  were  doomed  to  certain 
deatli.  The  medi(M)-h*g'aI  importance  of  ovarian  disease,  like  that  of 
tubal  disease,  has  but  lately  Ijcen  re(!Ognized.  In  herinaphrodites  (^ues- 
ti(ms  relatin*^'  to  the  ovaries  are  always  of  g-reat  significance,  and  the  sex 
of  an  individual  under  consideration  may  require  for  its  determination 
ill!  abdominal  operation,  inspection  of  the  jielvit;  organs,  and  differentia- 
tion with  the  aid  of  the  microscope  of  ovaries  from  testicles.  Unde- 
scended testicles  inay  be  mistaken  by  outward  examination  of  the  body 
for  ovaricis,  the  general  contour  of  the  person's  frame  and  the  appearance 
of  the  external  genitals  may  still  leave  one  in  doul)t  as  to  the  (juestion 
of  sex,  but  the  structure  of  tlie  organ  as  revealed  l)y  the  microscope 
will  usuaily  set  doubt  at  rest.*  l*ozzi  has  analyzed  three  remarkable 
biases  reported  by  ex(^eileut  (jrerman  authorities,  which  were  regarded  as 
illustrations  of  the  coexistence  in  the  same  person  of  testicles  and  ovaries. 
He  concludes  that  the  propositions  advanced  have  not  been  proved. 

The  condition  of  the  breasts  in  Iiermaphrodites  or  those  who  are  of 
doubtful  sex  may  prove  of  great  value  in  deciding  the  question  of  sex. 
In  some  cases  in  which  the  external  genitals  are  of  the  female  type,  the 
breasts  will  be  fiat,  the  nipple  poorly  developed,  and  the  mammary  gland 
rudimentary.  This  has  been  the  history  in  a  numl)er  of  recorded  cases 
of  hermaphrodites  of  gijiudide)-  variety,  but  other  cases  are  recorded  in 
which  the  reseml)lance  to  the  female  type  of  breast  is  unmistakaljle.t 

In  recent  years,  that  is,  since  the  era  of  abdominal  surgeiy  began,  and 
in  which  the  numl>er  of  operations  upon  the  essential  organs  of  genera- 
tion in  the  female  has  multiplied,  fewer  cases  of  doubtful  sex  have  been 
reported.  Should  they  be  necessary,  exploratory  operations  may  be 
resorted  to  in  cases  of  doul^tful  sex,  without  waiting  for  the  decision  of 
the  post-mortem  table. 

The  l)earing  of  the  foregoing  pages  upon  the  questions  of  fertility 
and  matrimony  is  direct  and  impoi-tant.  Marriage  being  a  contract  in 
the  eye  of  the  law,  and  one  which  may  be  dissolved  under  certain  adequate 
conditions,  it  follows  that  both  parties  to  the  contract  have  a  right  to 
know  beforehand  whether  each  is  in  such  physical  condition  that  the 
marriage  relation  can  be  properly  consummated.  It  is  assumed  that 
such  knowledge  is  lawful,  Ijecause  a  divorce  is  granted  in  cases  in  which 
physical  defects  prevent  the  consummation  of  the  marriage  relation. 
The  family  is  the  unit  in  civilized  society ;  it  is  essential  to  the  stability 
of  society  that  the  propagation  of  species  should  be  effected  under 
the  safeguards  of  the  family  ;  the  love  of  offspring  is  innate,  and  should 
be  encouraged  within  reasonable  limits,  and  is  one  of  the  bulwarks 
of  society  :  therefore,  whatever  our  views  as  to  the  morality  or  immorality 
of  divorce  may  be,  we  must  admit  that  society  can  protect  itself  only 

*  The  writer  is  aware  that  Zweifel  has  stated  that  tlie  ovary  and  testicle  in  early 
iiifaiiey  closely  reseiuhle  each  otlier  in  tlieir  anatomical  structure,  and  that  differen- 
tiation of  them  may  be  an  extremely  difficult  and  delicate  task.  (Pozzi,  loe.  cit.,  p. 
1079.) 

t  In  Von  Franquc's  case  (quoted  by  Garrigues,  IMann's  Sjistem  of  Gi/iiecnlogi/,  p. 
209  et  seq.),  the  individual  whose  picture  is  given  lias  a  strongly  marked  female  face, 
broad  liips  and  back,  long  hair,  and  finely  developed  breasts.  She  lived  as  a  woman 
until  her  forty-sixth  year;  tlien,  as  the  male  organ  of  copulation  was  strongly  devel- 
oped, and  as  a  whitish  fluid  was  discharged  from  it  during  coitus,  she  assumed  male 
.attire,  married,  and  lived  as  a  man  the  rest  of  lier  life. 


428  ^   SYSTEM  OF  LEGAL  MEDICINE. 

by  the  marriage  of  men  and  women  in  whom  the  reproductive  ap- 
paratus is  not  impotent.  This  is  fundamental  for  society  at  large,  and 
if  true  for  the  mass  it  should  be  true  for  the  individual.  But  absence  of 
otfsjjring  does  not  necessarily  imply  absolute  impotence  or  even  defect 
of  the  reproductive  apjjaratus  in  either  a  husband  or  a  wife ;  all  the 
organs  may  be  structurally  sufficient  for  the  projjer  performance  of  copu- 
lation, the  desire  for  offspring  ma}^  be  intense,  and  yet  the  desire  is  not 
gratified.  It  has  often  happened  that  in  some  of  these  cases  the  adop- 
tion of  suitable  medical  or  surgical  measures  brings  the  desired  end ;  in 
others  the  husband  or  wife,  by  marriage  with  some  other  person,  demon- 
strates by  the  presence  of  offspring  after  a  suitable  period  the  fact  of 
his  or  her  ability  to  beget  or  to  conceive.  Divorce  in  such  cases  must  be 
for  some  other  cause  than  physical  defect,  otherwise  husband  or  wife 
might  be  the  victim  of  grave  injustice.  What,  then,  are  the  conditions 
j)ertaining  to  the  reproductive  apparatus  which  render  marriage  invalid 
because  necessarily  infertile?  Plainly,  the  absence  of  those  organs 
which  are  essential  to  the  marriage  act  and  to  the  begetting  or  bearing 
of  offspring.  A  man  who  was  without  testicles  at  the  time  of  his  mar- 
riage would  be  absolutely  unable  to  beget  offspring.  But  a  man  without 
a  penis,  mth  one  which  is  rudunentary,  or  with  only  a  stump  resulting- 
from  disease  or  injury,  may  accomplish  the  sexual  act,  though  imper- 
fectly, and  may  beget  offspring.  It  woidd  therefore  be  a  question 
whether  a  woman  whom  he  may  have  married  could  seciu'e  a  divorce 
from  him  on  the  ground  of  his  impei'fection.*  Eunuchs  are  incapable  of 
begetting  offspring  because  deprived  of  testicles.  This  does  not  signify 
that  they  are  always  without  sexual  desii-e,  and  it  is  said  that  in  cases  in 
which  the  penis  has  not  been  removed  the  sexual  act  is  not  unusual. 

If  a  female  is  without  a  vagina  sexual  intercourse  and  conception 
are  both  impossible,  though  all  the  other  genital  organs  are  j)resent  and 
well  developed.  If  in  such  a  case  the  abdomen  were  opened,  the  uterus,. 
ovaries,  and  tubes  found  well  developed  and  without  apparent  disease, 
and  a  pseudovagina  were  made,  conception  might  be  possible  and  no 
ground  for  divorce  for  absolute  deformity  be  tenable ;  though  it  might 
be  m*ged  with  justice  that  the  woman  was  physically  defective,  for  the 
delivery  of  a  full-term  child  \)y  such  an  unnatural  passage,  if  possible  at 
all,  would  almost  certainly  result  in  the  death  of  the  mother  and  proba- 
bly in  that  of  the  child  as  well.  The  only  alternative  to  this  hazardous 
method  of  delivery  would  be  the  Cesarean  section.  Readily  as  such 
operations  ma}^  now  be  performed,  and  willing  as  the  writer  would  be 
on  all  suitable  occasions  to  perform  them,  he  would  in  no  instance  feel 
justified,  nor  deem  it  justifiable  in  another,  to  deliberate^  bring  about 
by  operation  upon  a  woman  such  conditions  as  would  expose  her  to  such 
great  risk  to  her  life.  There  are  many  women  who  express  a  willing- 
ness to  take  such  a  risk,  or  any  other  which  would  offer  to  them  the 

*  A  case  in  point  is  that  of  a  man  of  robnst  physical  development  and  defective 
moral  sense,  who  copulated  not  only  with  his  wife  but  with  numerous  other  women. 
Cancer  attacked  his  penis  and  it  was  ami>utated,  only  a  stump  of  insignificant  propor- 
tions remaining.  His  sexual  appetite  remained,  and  he  continued  to  liave  indiscrim- 
inate sexual  intercom-se.  He  stated  upon  inquiry  that  none  of  the  women  with  whom 
he  cohabited  experienced  any  difference  of  sensation  at  the  change  in  liis  condition. 
Whether  any  of  the  women  were  impregnated  after  his  operation  is  not  known,  but 
the  essential  elements  in  his  proereative  power  were  said  to  have  remained. 


BIRTH,  .^EX,    I'REGNANCY,  AMJ   DELIVERY.  420 

possiljility  of  maternity,  so  strong-  is  the  maternal  sense  \vitli  some 
women ;  but  the  writer  must  leave  to  others  the  cooperation  in  all  such 
eases,  which  to  his  mind  is  entirely  unwarrantable.  The  vagina  may  be 
normal  and  coitus  be  readily  accomplished,  but  if  the  uterus  is  al)sent  or 
extremely  rudimentary,  conception  will  be  impossible.  The  condition  of 
the  uterus  can  usually  be  ascei'tained  by  a  carefid  exaniinati(jn,  especially 
if  the  tissues  are  thoroughly  relaxed  by  the  administration  of  an  auics- 
thetic.  In  some  cases  a  decision  can  be  reached  only  l)y  in(dsion  of  tlie 
abdomen  and  direct  inspection  of  the  pelvic  organs.  In  hundreds  of 
cases  the  uterus  has  been  removed  for  serious  disease,  the  disease  being 
of  such  a  character  as  to  render  conception  improbable  or  impossible. 
It  has  freqiTcntly  been  successfully  removed  by  the  ^^^L■iter  under  such 
conditions. 

Absence  or  rudimentary  condition  of  the  Fallopain  tubes  render.s- 
conception  impossible.  Such  a  condition  resulting  from  congenital 
fault  is  rare,  but  disease  of  these  organs  not  infrequently  occurs  before 
marriage,  rendering  the  woman  hojielessly  sterile,  and  the  situation  is 
equivalent  to  that  in  which  they  have  been  removed  by  the  surgeon's- 
knife. 

Absence  or  rudimentary  condition  of  the  ovaries  places  a  woman  in 
a  condition  similar  to  that  w^hich  obtains  when  the  tubes  are  absent  or 
rudimentary.  Disease  in  the  tubes  and  the  ovaries  very  often  coexists, 
and  a  condition  which  demands  removal  of  the  tubes  demands  equally 
the  removal  of  the  ovaries.  There  is  no  law  which  forljids  hermaphro- 
dites to  marr}^,  but  as  marriage  with  such  individuals  is  ahnost  certain 
to  be  unfruitful  and  result  in  discontent  and  unhappiness,  and  as,  more- 
over, there  is  in  most  cases  legal  ground  for  divorce,  such  unions  are 
alwaj'S  to  be  discoiu'aged. 

The  period  which  is  known  as  that  of  puberty  marks  one  of  the  most 
important  and  critical  eras  in  the  life  of  every  individual,  whether  male 
or  female.  The  changes  which  then  take  place  are  marked  and  promi- 
nent, and  are  indicative  of  a  decided  transformation  in  the  physical  con- 
dition. Ripeness  of  intellectual  faculties,  however,  is  no  feature  of  this 
period,  though  it  has  been  stated  that  in  the  negro  race,  at  least  as  that 
race  has  been  observed  in  this  countrj^,  quickness  of  perception  reaches 
its  acme  at  puberty,  intellectual  progress  thenceforward  being  relati\-eh' 
slow.  From  the  period  of  pulierty,  at  whatever  age  it  may  occur,  the 
maturity  of  the  reproductive  apparatus  begins,  and  in  this  respect  the 
individual  is  as  completed"  equipped  functionally  as  he  will  ever  l.)e. 
Puberty  means,  therefore,  ripeness  of  the  procreative  power,  ability  to 
beget  or  to  couceive,  the  culmination  of  eliildhood,  and  immergence  into 
physical  maturity.  The  voice  of  the  boy  changes  at  that  time,  coarse 
hair  begins  to  grow  upon  the  skin  and  in  particular  surrounds  the  ex- 
ternal genitals,  the  sexual  appetite  is  aroused.  In  girls,  similar  phenom- 
ena upon  the  skin  are  apparent,  the  breasts  enlarge,  the  curves  of  the 
body  formed  by  the  development  of  the  muscles  and  fat  are  accentuated, 
and  the  inqxjrtant  function  of  menstruation  is  established.  This  fuiu^- 
tion  is  peculiar,  not  only  on  account  of  its  regular  recurrences,  its  sus- 
l)ension  under  certain  Avell-recognized  conditions,  notably  the  condition 
of  pregnancy,  but  also  from  the  fact  that  it  is  tlie  visible  exi^ression  and 
announcement  to  the  individual  that  the  period  of  puberty  with  all  its 
possibilities  has  arrived.     No  wonder  that  among  primitive  people  who- 


430  -^   SYSTEM  OF  LEGAL   2IEDICIXE. 

"were  iu  tlie  least  observaut  the  appearance  of  menstrnatiou  slioiild  be 
the  oecasiou  for  the  performance  of  appropriate  rites  and  ceremonies* 

There  are  numerons  factors  which  detewnine  the  time  and  the  man- 
ner of  the  establishment  of  puberty.  "\Miile  these  factors  are  influential 
for  both  sexes  thej'  ai-e  especially  so  for  the  female,  inasmuch  as  the 
female  is  usually  more  sensitively  organized  than  the  male.  They  may 
be  regarded  as  subjective  and  objective :  among  the  former  are  race  and 
family  pecnharities,  general  physical  condition,  temperament,  etc. ;  among 
the  latter  are  climate,  occupation,  altitude,  personal  habits,  etc.  (See  the 
wi'iters  ''Disorders  of  Menstruation,"  Trans.  X.  Y.  State  Medical  Society, 
1889,  p.  154.)  In  general  it  may  be  said  that  puberty  oceiu's  one  or  two 
years  earlier  in  girls  than  in  boys,  earlier  in  warm  than  in  cold  chmates, 
earlier  at  the  sea-level  than  at  high  altitudes,  earher  among  those  who 
are  healthy  than  among  the  sickly  and  dehcate,  earher  among  sav- 
ages than  among  the  ci^Tlized.  In  boys  puberty  is  most  fi'equently 
reached  between  the  thirteenth  and  sixteenth  years.  In  gii-ls  the  limits 
are  farther  apart :  it  may  occui-  as  early  as  the  eighth  or  as  late  as  the 
twentieth  year.  The  latter  limit  is  not  at  all  unusual  in  very  cold  cli- 
mates, while  in  the  tropics  menstruation  at  ten  years  of  age  is  not  j)re- 
cocious.  Even  in  our  own  climate  maturity  may  occur  very  early,  the 
widter  being  familiar  with  a  numl^er  of  instances  in  which  pregnancy 
occurred  between  the  tweKth  and  fourteenth  years. 

A  question  which  is  often  a  very  important  one  relates  to  the  coin- 
cidence or  want  of  coincidence  of  menstruation  and  ovidation.  Some 
writers  are  of  the  opinion  that  o^Tilation  may. begin  almost  at  bii"th. 
However  this  may  be,  it  is  certain  that  conception  does  not  usually  occur 
until  menstruation  has  been  established.  On  the  other  hand,  menstrua- 
tion often  occurs  with  considerable  regularity  when  the  ovaiies  are 
absent.  The  establishment  of  menstruation  is  often  a  slow  process — a 
discharge  of  blood  may  take  place  from  the  genitals,  with  the  attendant 
phenomena  of  the  nervous  system,  an  interval  of  several  months  may 
follow,  then  another  discharge  of  blood  lasting  several  days,  then  per- 
haps a  less  prolonged  interval  before  another  recuiTence,  and  finally, 
after  a  year  or  so,  the  recurrences  may  be  at  stated  monthly  periods :  or 
the  function  may  assume  fuU-fledged  peculiarities  fi-om  the  stai-t.  The 
discharge  of  bloody  fluid  continues  from  one  to  six  or  se^'en  days.  gTad- 
uaUy  increasing  in  Ciuantity  until  the  maximimi  is  reached,  and  then  as 
gradually  receding  and  disappearing.  There  may  be  no  accompanying 
j)henomena  which  are  worthy  of  note,  or  there  may  be  pain  iu  the  back, 
headache,  and  general  discomfort :  and  these  symptoms  vary  within  very 
wide  limits,  so  that  the  period  of  menstruation  is  justly  looked  upon  as 
one  of  the  most  important  in  the  functional  life  of  a  woman.  It  is  one 
which  often  calls  for  the  most  careful  attention  on  the  part  of  the  physi- 
cian. It  may  demand  examination  of  the  genital  organs,  and  sui-gical 
treatment  for  the  relief  of  f aidts  which  are  fundamental  to  the  menstraal 
disorder,  which  if  unrelieved  make  life  a  burden  during  a  not  inconsid- 
erable portion  of  every  month.     Earely  does  a  boy  reqim-e  the  same 

*  Among  the  American  Indians  at  the  Quapaw  (Ind.  Terr.).  Eoimd  Valley  (Cal.), 
and  Neali  Bay  (Wash.)  reservations  sueh  celebrations  are  observed.  The  ceremonies 
are  somewhat  disgusting  to  the  civilized  mind.  (See  the  wi-iter's  investigations  rela- 
tive to  the  functions  of  tlie  reproductive  apparatus  in  American  Indian  women.  Trans. 
Amer.  Gyn.  Soc,  vol.  xvi.,  p.  272.) 


BIRTH,  SEX,  riiEGNAMJY,  AM)   DELIVERY.  431 

careful  and  prolonged  supervision  as  a  girl  while  pul)erty  is  being  estab- 
lished, liii  certainly  should  be  instructed  during-  or  l)efore  that  period  con- 
cerning- tlie  control  of  his  sexual  appetite  and  the  care  of  the  sexual  organs, 
neglected  though  this  duty  nsually  is;  but  he  suffers  far  less  frequently 
than  the  girl  from  defects  and  disorders  of  his  sexual  organs,  and  far  less 
frequently  does  his  future  welfare  dei^end  upon  the  wise  counsel  and 
treatment  of  his  physician  at  this  time. 

Gynecology,  the-  science  which  deals  particularly  with  tiie  diseases 
peculiar  to  women,  has  done  very  much  to  mitigate  the  ills  and  e^•ils  of 
the  i)eri()d  of  puberty,  as  well  as  of  subsequent  periods;  and  if  it  has 
sometimes  showu  excess  of  zeal  in  the  treatment  of  such  conditions, 
which  call  for  tiie  highest  nuinifestations  of  tact,  skill,  modesty,  and  con- 
scientiousness, it  still  has  a  proud  record  in  the  relief  of  present  discom- 
fort and  the  wisdom  with  which  it  has  frequently  anticipated  trouble 
which  was  impending.  The  infiuenees  of  climate,  altitude,  and  the  gen- 
eral condition  of  the  individual  have  been  referred  to  as  factors  in  deter- 
mining the  early  or  late  appearance  of  pulierty,  and  we  have  also  seen 
that  in  some  cases  it  was  established  without  disturbance  while  in  others 
it  was  attended  by  pertm-l^ations  or  storms,  repeatedly  recurring,  until 
the  system  had  adjusted  itself,  as  it  were,  to  the  new  conditions.  In 
boys,  if  they  have  been  the  victims  of  nervous  disease,  such  as  ei:)ilepsy 
or  chorea,  the  disease  may  disappear  at  puberty ;  or,  on  the  other  hand, 
it  may  be  exaggerated,  especially  if  the  subjects  are  masturbators.  The 
same  is  true  with  regard  to  girls,  and  it  is  at  this  time,  also,  that  the  hys- 
terical temperament  is  wont  to  become  apparent.  It  nuiy  l)e  added  that 
this  is  also  the  Ijest  time  to  bring  it  under  control.  Insanity  develops  at 
this  period  of  life  with  far  less  frequency  than  at  the  period  which  ushers 
in  old  age  with  its  degenerative  tendencies  and  processes.  Malignant 
disease,  which  is  also  frequently  associated  with  the  period  of  senility 
and  decay,  seldom  makes  its  attacks  at  puberty.  Certain  serious  consti- 
tutional diseases,  such  as  pulmonary  consumption,  frequently  become  ex- 
aggerated at  this  time,  but  it  is  not  clear  that  this  is  necessarily  due  to 
any  influence  x)eculiar  to  jmberty.  On  the  whole  it  may  be  said  that  this 
period  should  be  as  conducive  to  robustness  of  physical  condition  as  any 
l)eriod  of  life,  for  it  is  the  time  of  youth  and  exuberant  physical  activity. 
Consequently  there  is  seldom  anything  in  the  experience  of  puberty  to 
impair  the  legal  accountal)ility  of  the  indi\ddual  in  so  far  as  a  stage  of 
legal  accountability  has  been  reached  at  that  epoch  of  moral  and  intel- 
lectual development. 

Menstruation  or  the  menstrual  flow  is  a  discharge  of  blood  and  other 
material  whicdi  is  derived  from  the  uterus,  ovaries,  and  Fallopian  tubes. 
It  recurs  with  considerable  regularity  each  lunar  month  in  females  who 
have  attained  the  age  of  pu])erty,  if  they  are  not  pregnant  and  ai-e  not 
suffering  with  any  wasting  disease.  It  continues,  as  we  have  already 
seen,  under  mn-nial  conditions,  from  one  to  six  or  seven  days.  It  is 
composed  not  only  of  l)lood  but  of  glandidar  secretions  and  degenerated 
t  issue-material,  and,  unlike  the  blood  under  its  ordinary  conditions,  does 
not  coagulate  or  clot  except  when  the  eii'cumstances  attending  its  dis- 
cliarge  are  unusual  or  pathological.  A  somewhat  analogous  discharge 
is  observed  among  many  of  the  lower  animals,  and  in  the  apes  and 
monkeys  it  has  decided  resemblances  to  the  monthly  flow  of  women. 
With  the  animals  the  flow  coincides  with  the  rut,  or  period  of  heat,  that 


432  ^   SYSTEM  OF  LEGAL  MEDICINE. 

is,  the  period  of  active  sexual  desire,  whicli  is  the  natural  expression  of 
functional  acti\T.t3^  of  the  reproductive  apparatus.  It  is  not  improbable 
that  the  function  of  menstruation  is  an  outgrowth  or  evolutionary  pro- 
cess of  the  conditiou  which  has  been  referred  to  in  animals.  Its  modi- 
fications and  varying  effects  are  apparent  enough  as  woman  advances  in 
the  scale  of  civilization  and  iutellectual  development.  One  of  the  char- 
acteristic f eatiu'es  of  the  menstrual  function  is  the  increase  in  the  tension 
of  the  Ijlood-vessels,  especially  in  those  which  suppty  the  genital  organs. 
The  tension  being  greater  than  the  resistance  of  the  superficial  vessels  in 
those  organs,  ruptui'e  and  hemorrhage  result.  "Wlien  menstruation  is 
performed  under  noiinal  conditions  it  gives  rise  to  no  particular  disturb- 
a^nce,  with  the  exception  of  the  annoyance  from  a  moist  and  sometimes 
malodorous  discharge,  and  even  this  annoyance  may  be  entirely  over- 
-come  \)j  the  use  of  suitable  means.  Like  all  the  other  functions  of  the 
body,  it  is  23ainless  when  it  is  normally  performed.  The  most  reasonable 
theory  in  regard  to  its  object,  and  the  one  which  comports  most  with  the 
analogous  function  in  the  lower  animals,  is  that  it  serves  as  the  expression 
of  the  fact  that  a  membrane  or  decidua  has  been  formed  in  the  uterus 
for  the  reception  of  an  ovum,  such  a  membrane  being  an  indisjDcn sable 
necessity  should  insemination  of  the  ovum  and  conception  occur.  Should 
such  a  result  not  occm*  the  unfertilized  oyuwl  passes  out  of  the  uterus, 
and  the  decidua,  mth  the  small  vessels  which  it  contains,  breaks  down 
and  is  washed  away  by  the  blood-current,  the  latter  forming  one  of  the 
phenomena  of  menstruation.  Should  this  phenomenon  fail  to  make  its 
appearance  at  the  customary  time,  it  is  often,  but  not  always,  the  sign 
that  conception  has  taken  jDlace.  The  abnormalities  of  the  menstrual 
function  are  many.  In  civilized  life,  especially  in  the  cities  and  among 
those  whose  manner  of  li^dng  is  artificial  and  highly  irregidar,  there  are 
more  women  who  experience  pain  and  annoyance  with  menstruation 
than  there  are  of  those  who  pass  through  it  uncousciously  and  naturally. 
This  might  be  regarded,  from  one  point  of  view,  as  an  argument  that 
civilization  had  acted  unfavorably  upon  the  physical  condiTiou  of  woman. 
The  faidt,  however,  is  not  exactly  that  of  civilization,  but  of  its  accom- 
paniments of  wealth  and  poverty,  vices  and  excesses,  neglect  to  inculcate 
in  the  j'oung  the  importance  of  hygienic  laws  and  precautions.  Among 
savages  and  barbarians  the  abnormalities  in  question  are  of  rare  occur- 
rence. The  following  digi'essions  from  normal  conditions  are  often 
observed : 

1.  Painful  menstniation,  or  dysmenorrhea. 

2.  Profuse  menstruation,  or  jDolymenorrhea. 

3.  Scanty  menstruation,  or  oligomenon-hea. 

4.  Absence  of  menstruation,  or  amenorrhea. 

5.  Irregular  or  substitutional  menstruation,  or  atopomenon'hea. 

The  first  of  these  abnormal  conditions,  always  referred  to  by  physi- 
cians as  dysmenorrhea,  is  so  common  that  many  physicians  are  of  the 
opinion  that  it  is  almost  a  necessary  and  unvarying  accompaniment  of 
the  function.  This  we  deny,  both  because  of  exjjerience  in  the  observa- 
tion of  many  cases  in  which  menstruation  was  absolutely  unaccompanied 
with  pain,  and  because  it  would  hardly  be  fan*  to  assume  that  so  impor- 
tant a  function  was  an  exception  to  all  the  other  functions  of  the  body 
in  being  normally  painful.  "With  many  women  pain  is  a  symptom  of 
menstruation  only  din-ing  the  earlier  vears  of  life,  nerhaps  until  they 


BIBTR,  SEX,  niEGNANCY,  AND  DELIVERY.  433 

liave  home  one  or  iiioi-e  (^liildren  ;  hut  with  others  it  is  a  eiistomnry  and 
oxpec-ted  and  ti'ying'  syin])toin  durin<>-  tlu^  entire  pei-iod  of  life  in  which 
menstruation  occurs.  It  is  most  fre([uently  located  in  some  portion  of 
the  head  and.  in  the  lumljar  region  of  the  ha(;k.  Very  often  it  is  also  in 
1lie  tliiglis  .and  legs  and  the  muscular  system  in  general.  It  may  be 
])r('se)it  during  the  entire  menstrual  pei-iod,  oi-  dui'ing  the  day  or  two 
])r('ceding  it,  or  it  may  not  occur  until  the  blood  l)egins  to  flow,  this 
form  being  less  common  than  the  others.  Pain  may  also  b(;  present  in 
the  stomacli  a.iid  l)ow('ls,  with  or  without  nausea  and  vomiting,  and  in 
the  uttn-iis  itself  in  the  form  of  cramps  or  contractions,  compMi'uble  to 
the  pains  of  labor,  and  oft(!n  due  to  the  blood  which  has  accMimulated  in 
tlie  organ,  which  it  takes  this  method  to  expel.  Young  and  unmarried 
women  are  the  greatest  sufferers  from  this  disorder,  but  the  married 
ones  and  those  who  have  borne  children  are  by  no  means  exempt.  The 
effect  of  these  repeated  iittacks  uj)on  the  mental  condition,  especially  in 
those  Avho  are  predisposed  to  mental  disturbance,  is  sometimes  very 
pronounced,  many  of  the  iniuivtes  of  lunatic  asylums  being  sufferers 
from  the  severer  forms  of  dysmenorrhea.  In  determining  the  cause  of 
insanity  it  is  very  important  to  ascertain  the  history  of  the  patient  with 
respect  to  her  menstrual  function. 

Profuse  hemorrhage  during  the  menstrual  period  is  sufliciently  com- 
mon, but  less  so  than  dysmenorrhea,  the  condition  just  described.  Its 
■cause  is  often  apparent  enough  vv^hen  there  are  tumors  in  the  uterine 
structure  or  when  the  mucous  membrane  of  the  uterus  is  diseased  from 
other  (pauses,  but  frequently  the  cause  is  obscure.  It  is  a  common  occur- 
rence in  young  girls  who  are  anemic  but  witliout  percepti))le  disease  in 
the  woml)  itself,  the  hemorrhage  rediTcing  their  strength  and  sometimes 
bringing  them  to  the  verge  of  collapse.  It  is  common  in  prostitutes  and 
others  who  have  abused  the  sexual  act,  in  those  who  have  suffered  abor- 
tion which  has  been  imperfectly  or  improperly  treated,  and  occurs  almost 
invariably  in  those  who  suffer  with  malignant  disease  of  the  womb  or  its 
appendages.  The  hemorrhage  may  appear  in  gushes,  in  clots,  or  in  a 
continuous  leakage  lasting  many  days.  In  some  cases  a  woman  has 
barely  time  to  rally  from  one  attack  before  she  is  seized  with  another. 
Unless  the  root  of  the  matter  can  be  quickly  reached  such  women  be- 
•come  hopeless  invalids,  djdng  from  exhaustion  or  becoming  an  easy 
prey  to  disease  of  some  other  character. 

Scanty  menstruation  may  be  an  indication  of  a  depraved  general 
condition  or  of  some  disturbance  located  in  the  genital  organs.  The 
menstrual  period  may  last  only  a  few  hours  or  it  may  extend  over  several 
days,  the  quantity  of  blood  lost  each  day  being  insufficient  to  relieve  the 
tension  in  the  T)lood-vessels  and  give  the  woman  a  sense  of  relief.  It 
may  be  due  to  a  sudden  checking  of  the  menstrual  flow  caused  by  low 
temperature,  a  high  wind,  a  cold  bath,  or  a  profound  mental  emotion. 
It  is  often  accompanied  with  severe  pain  (dysmenorrliea) ;  the  blood  itself 
may  be  pale  and  watery,  with  an  unusually  small  proportion  of  the 
constituents  (especially  the  red  corpuscles)  of  healthy  blood.  The  con- 
dition is  usually  amenable  to  relief,  either  Iw  measures  directed  to  the 
genei-al  condition  or  by  treatment  of  the  genital  organs  themselves ;  but 
it  is  far  less  frequently  an  expression  of  organic  disease  than  is  profuse 
menstruation,  and  far  less  calculated  to  cause  alarm  on  the  patient's 
behalf. 


434  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

Absence  of  menstruation,  or  amenorrliea,  is  relatively  an  infrequent 
condition,  those  cases  being  excluded,  of  course,  in  wliich  it  is  an  acconi- 
paninient  of  the  pregnant  state.  The  cause  is  sometimes  quite  beyond 
the  existing  state  of  our  knowledge,  but  at  others  a  rational  explanation 
is  entirety  possible.  It  sometimes  occurs  in  women  who  are  suffering 
with  severe  wasting  disease,  such  as  pulmonary  tuberculosis,  chronic 
Bright's  disease,  or  diabetes.  It  may  occur  in  connection  with  an  ocean 
voyage  or  residence  by  the  sea.  Many  of  the  young  immigrants  to  this 
country  suffer  in  this  way  for  months,  if  they  remain  at  the  sea-coast ; 
but  it  usiially  disappears,  leaving  no  bad  effects,  after  they  have  become 
accustomed  to  the  chmate.  It  is  sometimes  observed  in  women  who  are 
well  developed,  but  who  in  early  life  have  suffered  mth  chorea,  epilepsy^ 
or  some  other  disease  of  the  nervous  system.  Very  fat  women  occa- 
sionally suffer  in  this  way.  It  is  suggestive  of  pregnancy,  and  women 
who  are  thus  affected  frequently  consult  a  physician  in  great  alarm, 
fearing  pregnane}^,  especially  if  they  are  single  and  have  good  reason  for 
fearing  that  such  a  condition  might  exist.  It  is  a  common  superstition 
that  it  may  cause  or  lead  to  consumpiion.  This  it  never  does  in  and  of  itself. 
It  is  often  a  conservative  process  on  the  part  of  nature  when  the  woman 
is  too  weak  to  bear  without  detriment  the  loss  of  even  a  small  quantity 
of  blood ;  and  this  is  a  most  important  point  for  the  medical  jurist.  The 
superstition  alluded  to  is  probabh^  attributable  to  the  fact  already  men- 
tioned, that  it  may  be  an  incident  in  the  course  of  the  wasting  diseases. 
In  such  cases  it  is  both  post  Jwc  and  propter  lioc.  At  the  present  time, 
when  the  removal  of  the  ovaries  is  of  such  frequent  occurrence,  it  is  an 
almost  inevitable  result,  and  is  a  matter  of  daily  observation.  It  is  reme- 
diable in  many  waj^s — by  removal  of  the  residence  from  a  moist  to  a  dry 
climate,  by  improvement  of  the  general  condition,  and  by  removal  of  ex- 
isting causes  in  the  genital  organs.  It  is  irremediable  if  due  to  the 
removal  of  the  ovaries,  or  the  uterus  and  ovaries,  or  if  the  patient  is  suf- 
fering with  the  incurable  diseases  such  as  were  mentioned  as  its  causes. 

Irregular  or  displaced  or  substitutional  menstruation  is  the  variety 
which  has  often  been  called  \acarious  menstruation,  a  term  which  is  mis- 
leading and  objectionable.  The  somewhat  clumsy  term  atopomenorrhea 
is  suggested  as  a  substitute  which  is  correct  etymologically  and  explicit. 
It  is  a  substitute  for  menstruation  of  the  ordinary  t^-pe  or  it  may  be  a 
sort  of  addendum  to  it.  One  variety  of  which  the  writer  has  seen  several 
instances  consists  in  spots  or  patches  of  a  dark-red  color  upon  the  skin, 
known  by  dermatologists  as  purpura.  These  spots  are  caused  by  exuda- 
tions of  blood  from  the  vessels  beneath  the  surface  of  the  skin.  Xitvi  or 
birth-marks  are  usually  swollen  and  darker  in  color  than  usual  duiing 
menstiniation.  The  blood  or  blood-serum  may  even  exude  through  the 
skin  like  a  bloody  sweat,  and  cases  of  this  character  have  sometimes  ])een 
used  to  impose  upon  the  minds  of  the  superstitious  and  the  credulous. 
In  women  who  have  ulcers  or  open  sores  the  disr-harge  therefrom  is 
more  aljundant  during  the  menstrual  period  than  at  other  times,  on 
account  of  the  rise  of  the  blood-pressure  which  then  obtains.  Other 
varieties  of  atopouienorrhea  are  bloody  diarrhea,  bleeding  from  the 
gums,  the  nose,  the  anterior  chamber  of  the  eye,  vomiting  of  blood  from 
the  stomach.  Malingerers  have  been  known  to  swallow  blood,  or  red 
fluid  resembling  blood,  and  then  vomit  it  as  an  exhibition  of  abnormal 
menstruation,  especially  if  the  object  be  to  excite  attention  or  notoriety. 


BIRTH,  SEX,  rnEGXAXCY,  AXIJ   DELIVERY.  435. 

In  all  these  cases  it  becomes  the  duty  of  the  ph3-si('iaii  to  ascertain 
■wht'ther  the  tiuid  ejected  is  a  natural  product  or  Avhetlier  it  is  the  result 
of  fraud  on  the  part  of  tlie  individual,  the  opportunities  for  deceit  and 
imposition  heing'  abundant. 

Concerning-  the  relation  of  menstruation  to  gestation,  the  menstrual 
flow  and  its  attendant  phenomena  are  ordinarily  absent  during  gest;i- 
tion,  and  the  explanation  appears  in  the  theory  of  menstruation  which 
lias  been  given.  But  this  is  not  always  the  case :  some  women  menstru- 
ate regularly  while  pregnant  the  same  as  in  the  nnimpregnated  state. 
In  the  dangerous  eoiulition  known  as  placenta  pranda,  in  whi(!h  thi-;  pla- 
centa is  inii)lanted  directty  over  the  internal  opening  of  the  womb,  a  dis- 
charge of  l)lood  occurs  every  month  and  ma}^  result  in  aljortion  or  eveu 
in  fatal  consequences.  If  mahgnant  disease  coexists  with  pregnancy,  hem- 
ori'liage  may  take  place  either  at  the  custonuiry  time  of  menstruation  or 
at  irregular  intervals.  In  aU  cases  of  pregnancy  in  which  hemoii-hage 
takes  place,  whether  at  regular  or  ii-regular  intervals,  it  is  very  desii'able 
to  ascertain  its  cause,  for  serious  consequences  may  thereby  be  averted. 

If  the  meiisti'ual  flow  occurs  in  any  other  than  the  normal  manner — if 
it  is  too  aliundant  or  too  scanty,  if  it  continues  too  long,  at  too  frequent 
or  at  too  infrequent  intervals — its  cause  should  be  ascertained  as  promptly 
as  possible.  It  has  been  shown  that  such  irregularity  may  be  associated 
Nvith  disease  of  the  uterus,  the  Fallopian  tubes,  or  the  ovaries,  and  the 
bearing  of  -Any  such  possible  conditions  must  be  carefuUy  determined. 
Gonorrhea  involving  any  of  the  genital  organs  may  produce  a  bloody 
discharge ;  also  syphilis,  abscess  of  the  pelvis,  or  pelvic  congestion  from 
any  other  cause.  Certain  diseases  of  the  bladder  and  urethra  are  also 
accompanied  with  hemorrhage,  and  such  a  discharge  must  not  be  mis- 
taken for  the  menstrual  flow.  Bloody  discharges  fi'om  the  rectum  and 
anus  must  also  be  carefully  referred  to  their  proper  origin  and  not  be 
hastily  regarded  as  an  evidence  of  abnormal  menstruation.  It  will  there- 
fore be  apparent  that  all  discharges  of  blood  from  the  female  genital 
organs  ar«  of  very  decided  significance,  and  only  by  careful  attention 
can  their  true  natiu-e  be  determined. 

The  menopause,  or  change  of  life  as  it  is  commonly  called,  marks  one- 
of  the  important  eras  in  the  life  of  a  woman.  Puberty  announces  the 
initiation  of  the  cliild-l)earing  period,  the  menopause  its  termination. 
By  this  term  is  meant  primarily  the  cessation  of  the  menstrual  funetiou. 
In  temperate  climates  it  occurs,  in  the  great  majority  of  instances,  be- 
tween the  fortieth  and  fiftieth  years.*  In  very  warm  and  in  ^Tiy  cold 
climates  it  often  occm-s  prior  to  the  fortieth  year.  Those  who  reach 
puberty  early  frequently  reach  the  menopause  late  in  life.  Those  who 
bear  many  children  in  rapid  succession,  also  those  who  are  very  fat, 
usually  cease  menstruating  early.  The  same  is  true  of  those  who  suifer 
with  the  wasting  and  exhausting  diseases  :  as  was  remarked  in  a  pre\ioiis 
part  of  this  article,  the  limit  of  the  reproductive  force  has  been  reached, 
and  is  evidently  dependent  upon  the  general  condition  of  nutrition  of 
the  body.  Those  whose  ovaries  have  been  removed  experience  the  meno- 
pause as  the  direct  consequence  of  such  an  operation. 

*  This  rule  is  very  far  from  universal  in  its  application.  The  Avriter  has  known 
many  instances  in  which  menstrnation  Ims  occurred  as  late  as  the  fifty-fourth  year 
without  interruption.  Very  late  occurrence  of  the  menopause  is  a  noteworthy  char- 
acteristic in  many  families. 


436  ^  SYSTEM  OF  LEGAL  MEDICINE. 

The  menstrual  function  may  terminate  abruptly  or  gradually,  tlie 
interval  between  the  periods  gradually  lengthening  iintil  they  cease  alto- 
gether. If  a  bloody  discharge  from  the  genitals  recurs  after  the  meno- 
pause has  taken  place  it  may  be  regarded  as  an  unfailing  evidence  of 
disease,  and  it  is  usually  an  e\ddence  of  serious  disease.  No  one  of 
exiDcrience,  nowadaj^s,  would  think  of  attributing  to  menstruation  a 
hemorrhage  or  series  of  hemorrhages  occurring  five  or  ten  years  or  even 
longer  after  the  disappearance  of  the  menstrual  function,  though  such 
diagnoses  were  common  enough  in  the  practice  of  a  generation  ago  and 
earlier. 

The  menopause  marks  not  onlj^  the  cessation  of  menstruation  and 
the  child-bearing  function,  but  the  advent  of  diminished  resisting  power 
of  the  tissues  and  organs  to  disease  processes.  Repair  now  takes  place 
less  readily  than  in  the  previous  years  of  life,  and  the  individual  is  more 
susceptible  to  disease.  Cancer  and  other  malignant  and  degenerative 
processes  are  prone  to  develop,  also  insanity'  and  other  diseases  of  the 
nervons  system. 

Women  who  are  passing  through  the  menopause  are  often  troubled 
with  sudden  flashes  of  heat  upon  the  surface  of  the  body,  especially 
about  the  face  and  head,  w^hich  appear  without  warning  and  vanish  as 
mysteriously ;  they  may  snif er  with  unaccountable  attacks  of  hysteria, 
with  disorder  of  the  stomach,  liver,  and  bowels,  or  with  great  irritation 
of  the  kidnej^s  and  bladder.  In  fact,  if  the  menopause  is  a  stormy  one, 
as  it  very  often  is,  they  are  to  be  judged  by  a  different  standard  of  phj^s- 
ical  condition  and  behavior  from  that  which  is  applicable  to  younger 
women  or  to  those  who  are  fortunate  in  getting  through  it  without 
I)articular  perturbation.  In  consideration  of  the  many  possibilities  of 
discomfort  of  this  period  a  grave  responsibility  is  laid  upon  the  gyneco- 
logical surgeon  who  may  be  caRed  upon  to  perform  an  operation  which 
win  precipitate  it.  The  frequency  with  which  this  operation  is  done 
sometimes  gives  rise  to  the  suspicion  that  these  possibilities  have  not 
been  weighed  with  sufficient  care.  The  subject  is  certain  to  require  more 
profound  and  extensive  consideration  at  the  hands  of  the  jurist  than  it 
has  heretofore  received.* 

In  women  who  are  the  victims  of  fibroid  tumor  of  the  nterus  the 
menopanse  usually  comes  later  than  with  those  who  are  free  from  such 
disease.  Schorler  (see  GTnsserow,  NeuMMungen  des  Uterus,  p.  28)  found 
the  average  age  of  the  menopause  in  women  without  tumors  to  be  47.13 
years.  Of  those  who  had  tumors  the  average  of  29  in  private  practice 
was  49.14  years,  and  of  23  in  hospital  practice  48  years.  In  Gusserow's 
investigations  menstruation  persisted  at  50  years  in  5.4  percent,  of  aU 
cases  of  filjroid  tumor  of  the  nterus  in  private  practice,  and  in  7.7  per- 
cent, in  hospital  practice.  The  teaching  that  fibroid  tumors  of  the  nterus 
are  quiescent  and  harmless  after  the  menopause  is  frequently  erroneous. 
The  Aviiter  recently  removed  the  uterus  with  a  large  fibroid  tumor  which 
-svas  firmly  fixed  in  the  pelvis  and  actively  growing  from  a  woman  who 
had  passed  the  menopause  two  years  previously.  The  tumor  was  abun- 
dantly nourished  l;)y  the  adhesions  in  which  it  was  ensheathed. 

*  In  this  connection  see  a  timely  article  by  Goodell,  "  The  Effect  of  Castration  on 
"Women,  and  other  Problems  in  Gjaiecology,"  Annals  of  Gynecology,  January,  1894, 
p.  198. 


BIETH,  SEX,  rUEuyAXCY,  JSU   DELlVEliY.  437 


III.    PKEGNAXCY. 

Marri(i(/e  and  Coiiccpfioii — Sfi'riJifij — Evidences  of  Pregnancy  in  its  Early 
Sfaycs,  also  in  its  Later  stages — Conditions  which  simulate  Pregnancy 
— ISitperfetation — Complicated  Pregnancies — Age-liniifa  irithin  n:hich 
Pregnancy  is  Possible — Can  Pregnancy  Ej-ist  and  the  Mother  he  Igno- 
rant of  the  Fact? — Viability — Duration  of  Gestation  under  Ordinary 
and  Extraordinary  Conditions — I)eterniinatio)i  of  the  Period  tcJiich 
Pregiiancy  has  Beached  in  a  Given  Case — Legal  Questions  Relating  to 
the  Foregoing. 

Marriage  implies  the  possibility  of  sexual  intercourse ;  sexual  inter- 
course during-  the  child-bearing  jjeriod  implies  the  possibility  of  concep- 
tion :  judging  from  analogy  in  many  of  the  lower  animals,  that  is  its 
phj^siological  object  and  not  solety  the  gratification  of  the  sexual  appe- 
tite. If  conception  does  not  take  place  after  sexual  intercourse  it  is 
because  the  conditions  as  to  ovulation  are  unfavorable,  or  because  of 
physical  disability  on  the  part  of  the  man  or  the  woman,  or  because  of 
mechanical  interference  in  some  way  or  other.  This  statement  is  com- 
prehensive enough  to  answer  and  explain  many  facts  and  questions.  It 
explains  the  failure  of  countless  women  to  become  pregnant  though  they 
and  their  husbands  long  for  children  with  earnest  longing.  It  explains 
the  failure  of  other  women  to  become  pregnant  who  would  not  submit  to 
pregnancy  and  labor  if  there  were  any  possible  way  of  a^-oiding  it.  It 
also  suggests  the  explanation  of  pregnancy  when  it  occurs  against  the 
will  of  the  pregnant,  and  when  they  were  under  the  impression  that  they 
had  used  all  the  means  which  were  necessary  to  prevent  conception.  It 
is  not  affirmed  by  the  writer  that  absolute  non-interference  ])rior  to  con- 
ception is  the  proper  and  only  line  of  conduct  to  be  followed.  In  this 
respect  he  is  well  aware  that  all  of  his  medical  brethren  will  not  agree 
with  him.  It  seems  to  him  that  there  are  cases  in  which  interference  to 
prevent  conception  is  desirable  and  just,  and  not  injiuious  to  the  ph^-sical 
condition  of  either  the  husband  or  the  wife.  Indiscriminate  intercoui'se 
between  those  who  are  not  married  to  each  other  is  excluded  as  at  all 
times  immoral,  unnecessary,  and  improper.  That  men  and  women  are 
•often  very  badlj^  mated  is  abundantly  sho"RTi  by  the  hideous  mental, 
physical,  and  moral  monstrosities  and  deformities  which  result  from 
such  unions.  It  ^\'ould  be  well  for  the  world  if  the  reproductive  power 
of  many  individuals  Avere  terminated.  A  stock-raiser  who  should  breed 
his  animals  with  no  more  care  and  thoughtfulness  than  is  exercised  by 
the  average  of  human  beings  woidd  soon  be  compelled  to  go  out  of  the 
business.  G-reater  "wisdom  in  the  pau-ing  of  men  and  women,  "wisdom 
<ind  judgment  in  the  getting  and  rearing  of  offspring,  may  result  iu 
fewer  children,  but  they  will  be  better  than  the  present  average,  and 
marriage  mil  have  less  misery  and  bitterness  connected  vnX\\  it. 

After  conception  has  taken  place,  to  interrupt  it  is  to  destroy  life, 
and  this  is  rarely  warrantable.  In  many  years  of  city  practice  the 
writer  has  seen  but  two  cases  in  which  such  practice  seemed  to  him  jus- 
titialile.  In  one  the  mother  was  reduced  by  persistent  vomiting  to  such 
a  degree  of  exhaustion  that  longer  delay  woidd  almost  certainly  have 
resulted  in  death.     The  case  was  seen  in  consultation  and  its  OTavitv 


438  -^   SYSTEM   OF  LEGAL  MEDICINE. 

appreciated,  l^iit  tlie  operation  was  uot  performed  until  tlie  patient  had 
been  seen  hy  an  obstetrician  of  great  eminence  and  wisdom,  who  con- 
cniTed  in  its  propriety.  In  the  other  case  the  alternati"S'e  would  have 
been  a  serious  cutting  operation  at  or  near  the  conclusion  of  pregnancy. 
Such  an  alternative  would  at  the  present  time  be  adopted,  at  least  in  the 
majority  of  cases,  but  at  that  earher  j^eriod  it  would  not  have  been 
deemed  advisable. 

Stei'ility  is  the  term  which  is  commonly  apphed  to  the  condition  of 
unfruitfulness  in  a  married  woman.  But  a  man  may  be  sterile  as  well 
as  a  woman,  and  this  condition,  whether  in  man  or  in  woman,  may  be 
relative  or  absolute.  The  result  of  the  marriage  of  Napoleon  I.  and 
Josephine  was  sterihty  and  divorce,  though  the  latter  as  Josephine  Beau- 
harnais  had  borne  two  childi-en  prior  to  her  marriage  with  Napoleon, 
and  he  was  subsequently  a  father  by  Marie  of  Austria.  This  familiar 
example  has  had  many  counterparts.  Absolute  sterility  is  necessarily 
present  when  those  orgaus  which  are  essential  to  rej)roduction  are  want- 
ing. This  matter  has  been  elaborated  at  sufficient  length  in  the  section 
relating  to  hermaphrodism  and  i-udimentary  aud  defective  organs. 

Eelative  steiilitj^  refers  uot  merely  to  the  incompatibility  of  a  given 
man  and  woman  for  each  other  with  reference  to  having  offspring,  but 
also  to  the  inabihty  of  either  to  perform  the  necessary  part  in  the  expe- 
riences connected  mth  reproduction  during  a  prolonged  period  of  time. 
Thus  a  woman  who  has  no  children,  after  ha^dng  had  one  or  more, 
during  five  or  ten  successive  years  is  relatively  sterile.  Or  the  relative 
sterility  may  be  due  to  some  physical  defect  in  the  man  or  the  woman  oi- 
both  wliich  in  time  is  remedied  and  thej'  ultimately  have  offspring.  In 
the  man  the  condition  of  episj)adias  or  lij^^ospadias,  or  a  defect  of  some 
other  character  in  the  organ  of  copulation,  may  prevent  insemination  of 
Ms  wife  though  his  testicles  and  their  secretion  may  l^e  normal.  Or,  on 
the  other  hand,  the  semen  may  be  lacking  in  \dtality,  the  spermatozoa 
being  few  or  inactive.  Such  a  condition  is  frequently  remediable  by 
such  measures  as  careful  diet,  stimulating  exercise,  or  tonic  drugs.  In 
any  case  it  must  be  remembered  that  it  is  premature  to  pronounce  a 
woman  sterile  until  the  condition  of  the  genital  organs  and  the  secre- 
tions of  her  husband  has  been  ascertained,  and  this  may  necessitate  one 
or  more  microscopical  examinations  of  the  semen,  the  examinations  being 
made  mth  the  greatest  care  and  dehcacy  immediately  after  the  semen 
has  been  discharged.  A  great  variety  of  conditions  in  women,  in  addi- 
tion to  those  which  have  been  mentioned  as  causing  al3solute  sterility, 
may  prevent  conception.  A  thickened  and  nearly  unper\dous  hpneu 
may  prevent  effective  access  of  the  spermatozoa  to  the  uterus  ;*  an  abun- 
dant and  acrid  vaginal  secretion  may  destroy  the  vitality  of  the  sperma- 
tozoa ;  and  equally  effective  causes  of  sterility  may  consist  in  indm-ation 
of  the  vaginal  portion  of  the  cervix  uteri,  w\t\\  very  minute  external  open- 
ing of  the  same,  catan-hal  inflammation  of  the  lining  membrane  of  the 
womb,  also  acute  anterior  or  posterior  displacement  of  the  womb.  All 
these  morbid  conditions  are  usually  remediable  by  proper  surgical  pro- 
cedures, and  if  the  other  necessary  prerequisites  to  conception  are  present 

*  Such  an  obstruction  is  not  always  efficient.  Grandin  reports  a  ease  {New  Torlc 
Journal  of  Gifnecolngij  mid  Obstetricf<,  November,  1893)  in  which  impregnation  occui'red,, 
the  e%'idence  being  conclusive  that  introduction  of  the  penis  was  impossible. 


BIRTn,  SEX,   riiEGNAXCY,  AND   DELIVERY.  439 

the  case  cannot  l)e  rciii'arded  as  one  of  absolute  sterility.  In  not  a  feAV 
instanees  the  writer  has  had  the  satisfaction  of  a  practical  ac(juaintance 
with  women  in  whom  the  difficulties  wliicli  have  been  alluded  to  have 
been  overcome  ;  and  to  a  woman  with  whom  the  maternal  sense  is  strong 
there  is  no  greater  boon-  than  the  satisfaction  of  that  sense.  More  diffi- 
cult of  treatment  than  any  witli  such  abnormalities  as  have  been  men- 
tioned are  those  cases  in  which  the  sterility  depends  upon  serious  disease 
of  one  or  both  of  the  ovaries  or  the  Fallopian  tuljcs.  In  such  cases 
entire  organs  or  parts  of  organs  must  be  removed,  and  the  pai-ts  whi(;h 
are  retained  must  be  Ijrought  into  such  relations  as  to  functionate  as 
nearly  as  possiljle  like  the  organs  in  their  natnral  condition.  To  over- 
come such  obstacles  and  thus  facilitate  a  succeeding  pregnancy  is  a 
trium})li  of  snrgical  art.*  A  method  of  overcoming  sterility  which  was 
ardentl}^  advocated  by  the  elder  Sims  and  practiced  by  him  as  well  as  by 
other  gynecologists,  especially  by  those  of  the  French  school,  consists  in 
artificial  insemination,  the  semen  being  collected  from  the  vagina  and 
introduced  into  the  nterus  by  means  of  a  clean  glass  tube  as  soon  as 
possi].)le  after  it  has  been  deposited  in  the  vagina.  This  method  is 
attended  with  many  difficulties  and  has  been  so  seldom  successful  that 
it  has  not  been  generally  adopted  by  the  profession.t 

The  question  of  overcoming  sterility  is  often  an  important  one  in 
connection  with  the  inheritance  of  estates.  It  is,  of  course,  justifiable 
and  proper  to  use  all  available  means  for  the  attainment  of  this  end.  It 
is  useless  to  attempt  it  in  cases  in  which  absolute  sterility  is  present,  and 
suspicion  must  necessarily  be  aroused  in  such  cases  if  a  child  is  brought 
forward  as  a  claimant  for  property.  If  the  condition  is  one  of  relative 
sterility  it  is  proper  to  extend  the  hope  that  the  difficulties  may  be  over- 
come and  a  child  obtained,  even  though  a  long  course  of  medical  or 
surgical  treatment,  perhaps  continuing  for  years,  be  necessary  for  its 
accomplishment.  This  result  will  seldom  be  accomplished  by  artificial 
insemination,  though  the  trial  of  such  a  method  will  be  warranted, 
especially  if  other  measures  have  been  tried  without  success. 

*  A  ease  of  this  character  has  occurred  in  the  wi'iter's  practice,  and  is  so  unusual 
in  its  particulars  that  he  feels  justified  in  narrating  it  at  some  length.  The  patient 
was  a  young  Irishwoman,  twenty-three  years  of  age,  who  was  first  seen  October  20, 
1888,  eighteen  montlis  after  her  marriage.  She  had  never  been  pregnant,  though  in- 
tensely desirous  of  offspring.  Her  womb  was  retrofiexed  and  fixed  by  firm  adhesions. 
After  various  attemjits  to  relieve  her  by  mild  measiu-es,  which  were  entirely  unsuc- 
cessful, she  consented  to  have  the  abdomen  opened  and  a  radical  operation  performed. 
The  womb  was  forcibly  detached  from  its  improper  position,  brought  forward,  and 
secured  by  silver  wires  passed  through  each  horn  to  the  abdominal  wall  (January  8, 
1891).  Both  ovaries  were  diseased.  The  right  one  was  as  large  as  a  man's  fist,  and 
with  its  corresponding  Fallopian  tube  was  removed.  Tlie  left  ovary  was  enlarged  to 
the  size  of  a  hen's  egg,  Imt  contained  a  certain  portion  of  tissue  wliicli  seemed  to  bo 
normal.  The  diseased  tissue  was  cut  away,  the  remaining  fragment  properly  stitched 
and  brought  into  relatively  normal  relations  with  its  tube,  and  tlie  al)doniinal  wound 
closed.  The  operation  resulted  in  recovery  and  in  great  improvement  in  tlie  general 
condition.  After  ten  months  she  became  pregnant,  and  at  the  proper  time  (September 
8,  1892)  was  delivered  by  tlie  writer  of  a  fine,  large  female  child. 

t  Personal  communication  with  Dr.  Harry  Marion  Sims  in  regard  to  tlie  experience 
•of  his  father  with  the  subject  of  artificial  insemination  revealed  the  fact  that  this 
metliod  is  not  only  a  very  troublesome  but  a  very  unsatisfactory  one.  The  elder  Sims 
practiced  it  in  fifteen  cases,  and  in  only  one  did  pregnancy  result,  and  tlion  it  occurred 
only  after  sixteen  operations.  Dr.  Harry  iMarion  Sims  has  also  tried  the  method  in 
eiglit  cases,  and  in  iione  of  them  did  his  etTorts  result  in  pregnancy.  If  the  method 
fails  in  such  skillful  hands  others  nuiy  well  despair. 


440  ^   SYSTEM  OF  LEGAL  MEDJCIXE. 

Gestation  or  pregnancy  is  tliat  physiological  condition  in  the  female- 
which  is  essential  to  the  reproduction  of  species.  It  impUes  the  effective 
union  of  spermatozoon  and  o\Tim  and  theii'  subsequent  development. 
It  does  not  imply  anything  in  regard  to  the  result  of  the  process.  It 
implies  the  existence  of  the  essential  genital  organs — the  vagina,  uterus, 
Fallopian  tubes,  and  ovaries.  'S^'Tien  the  condition  proceeds  normally 
the  products  of  concex)tion  are  in  the  cavity  of  the  uterus — that  is  the 
normal  nidus  of  the  human  ovum.  There  are  many  instances,  however, 
in  which  pregnancy  has  taken  place  outside  the  uteras,  in  some  cases 
jDroceeding  without  interruption  to  the  end  of  the  period  which  is  neces- 
sary for  the  full  development  of  the  fetus,  in  others  suffering  interrup- 
tion at  an  earty  stage,  with  consequent  destruction  of  the  fetus,  and 
often  with  fatal  result  to  the  mother  as  weU.  The  greater  number  of 
these  extra-uterine  or  ectopic  pregnancies  undoubtedly  take  place  in 
some  portion  of  the  Fallopian  tubes.  Some  writers  of  the  highest 
authority  deny  that  they  can  ever  take  place  anywhere  else,  but  it  does 
not  seem  to  the  writer  impossible  that  spermatozoa  should  work  their 
way  thi'ough  a  tube  and  meet  an  o^^.lm  just  as  it  was  extruded  from  a 
ruptui'ed  Grraafian  foUicle.  Should  that  occur  and  union  of  the  two 
elements  take  place,  it  would  seem  quite  possible  that  development  of 
the  fructified  ovum  might  take  place  upon  the  ovary  or  even  within  the 
free  abdominal  ca^dty.  A  number  of  cases  are  recorded  in  which  it  has 
been  asserted  that  true  ovarian  pregnancy  was  present ;  also  a  number  of 
eases,  including  one  of  the  writer's,  in  which  the  pregnancy  seemed  to 
have  been  hmited  to  the  abdominal  cavdty.*  Some  of  the  specimens  of 
these  cases  are  preserved  in  medical  museums,  and  they  have  been  exam- 
ined by  various  experts,  some  of  whom  admit,  while  others  deny,  that 
they  represent  ovarian  or  abdominal  pregnancy.  The  subject  is  still  in 
dispute.  It  is  much  easier  to  believe  that  impregnation  takes  place,  in 
these  extra-uterine  cases,  in  some  portion  of  the  tube  rather  than  upon 
the  ovary  or  intestine  or  other  portion  of  the  surface  of  the  peritoneum, 
and  it  is  quite  possible  that  an  ovum  inseminated  at  the  fringed  extrem- 
ity of  the  FaUopian  tube  might,  after  a  short  time,  fall  or  di-op  from  its 
primary  place  of  attachment  and  locate  itself  anew  on  the  surface  of  the 
ovary  or  elsewhere.  In  the  unmistakable  tubal  pregnancies  the  tumor 
may  develop  in  any  portion  of  the  tube  and  the  remaining  portion  may 
present  a  normal  appearance.  In  the  great  majority  of  cases  the  tubal 
timior  ruptiQ-es  fi'om  the  sixth  to  the  tenth  week  of  gestatiou,  the  open- 
ing being  into  the  free  peritoneal  caWty  or  into  the  folds  of  the  broad 
ligament  which  lie  under  the  tumor.  In  the  former  case  the  fetus  may 
be  precipitated  into  the  free  abdominal  cavity,  usually  dying,  but  in  rare 
cases  retaining  its  life  and  developing  in  this  strange  situation.  Such 
cases  are  often  fatal  to  the  mothers  from  hemorrhage.  In  the  latter  case 
a  roomy  pouch  is  found,  to  which  the  fetus  adapts  itself,  and  develop- 
ment may  continue  in  this  situation  until  the  child  has  reached  maturity. 
From  this  position  it  can  be  extricated  only  as  it  is  removed  through  an 
incision  in  the  abdomen  or  the  vagina,  or  after  the  slow  process  of  de- 
composition has  taken  place,  the  bones  and  other  solid  tissues  ulcerating 

*  In  the  writer's  ease  a  fetus  of  the  fifth  month  or  possibly  later  was  found  in  the 
mother's  abdomen  after  death.  So  far  as  could  be  judged  at  the  time,  from  the  con- 
dition of  the  uterus,  tiibes,  and  ovaries,  none  of  these  organs  had  been  at  any  time 
the  seat  of  this  ju'egnaucy. 


BIHTU,  SEX,    I'REOXAXCY,  AXD   DELIVERY.  441 

tlieir  way  tlirong'li  the  re(;tuin,  Ijladder,  vao'iu;!,  or  aluloiiiiiial  wall.  Very 
few  woiueii  are  al)le  to  eudure  the  strain  of  siu-li  a  t('rril)le  process.  Ex- 
tra-uterine pregnancy  oecurs  much  more  frequently  than  was  formerly 
supposed,  but  it  would  probably  be  mueh  more  frequent  still  if  impreg- 
nation began,  as  is  nuiiutained  by  many  writers,  in  the  Fallopian  tubes, 
the  ovum  then  descending  into  the  uterus.  It  would  seem  more  reason- 
able to  believe  that  the  sperm  and  germ  cells  meet  and  unite  in  some 
portion  of  the  uterine  cavity,  and  that  when  this  does  not  take  phu^e  it 
is  because  of  some  abnormality  in  the  uterus,  the  tubes,  or  the  ovaries. 
A  number  of  cases  of  tu]>al  pregnancy  in  the  writer's  knowledge,  in  which 
such  abnormalities  have  been  present,  have  eoutirmed  his  views  in  regard 
to  the  correctness  of  these  statements. 

The  ovum  and  spermatozoon  having  united,  conception  becomes  a  fact, 
the  ovum  becoming  imbedded  or  implanted  in  the  uteriue  mucous  mem- 
brane, and  developing  in  accordance  Avith  physiological  laws  which  have 
been  carefully  investigated  and  clearly  determined,  and  which  are  embod- 
ied in  the  beautiful  science  of  emliryology.  If  pregnancy  proceeds  normally 
the  first  evidence  or  iutinuition  of  its  presence  to  the  woman  consists  in 
the  absence  of  the  menstrual  flow  when  the  time  for  its  apjDearance  has 
arrived.  At  this  early  stage  of  gestation  the  ovum  may  be  readily  dis- 
lodged, and  mau}^  abortions  are  produced  by  the  drastic  remedies  which, 
are  taken  by  women  who  are  alarmed  because  their  "sickness"  does  not 
appear.  If  the  ovum  is  not  disturbed  and  the  time  for  the  menstrual 
flow  recurs  again  with  experience  similar  to  that  of  the  preceding  mouth 
the  hope  or  suspicion  of  pregnancy  which  was  entertained  by  the  woman 
wiU,  in  most  cases,  have  developed  into  a  certainty.  If  the  woman  is 
pregnant  for  the  first  time  she  will  usually  be  a  sufferer  with  nausea  and 
vomiting,  especially  in  the  early  hom-s  of  the  day  (morning  sickness) ;  her 
breasts  will  begin  to  enlarge,  and  perhaps  be  pixinful.  In  a  certain  num- 
ber of  cases  there  will  be  milk  in  the  breasts,  but  this  is  by  no  means  a 
customary  occurrence.  The  changing  contour  of  the  abdomen  will  com- 
l)el  the  woman  to  loosen  her  clothes  about  her  waist.  Cousti});ition  will 
frequently  be  a  troublesome  symptom,  also  an  abundant  leucorrheal  dis- 
charge from  the  vagina.  The  appetite  may  be  increased,  and  the  strug- 
gle between  increase  of  the  appetite  and  inability  to  retain  the  food 
which  is  taken  is  often  very  distressing.  Such  ai'e  the  principal  sub- 
jective symptoms  during  the  first  two  months  of  pregnancy.  If  a  phy- 
sician is  called  on  account  of  the  non-appearance  of  the  menstrual  flow 
at  the  customary  time  he  may  be  assisted  in  his  diagnosis  by  the  state- 
ments of  the  patient,  or  they  may  be  intended  to  mislead  and  deceive 
him;  he  should  therefore  be  on  his  guard  against  deception  and  de])end 
upon  objective  rather  than  su])jective  symptoms.  He  should  refrain 
from  introducing  instruments  into  the  uterus,  as  he  might  inadvertently 
punctui-e  the  ovum,  produce  an  al)ortion,  and  thus  accomplish  the  very 
end  which  his  patient  desired,  though  she  may  not  have  expressed  such 
a  desire.  If  the  pregnancy  has  not  advanced  beyond  the  fourth  or  fifth 
week  a  positive  diagnosis  of  the  condition  may  be  very  difficult  or  even 
impossil)le.  An  examination  with  the  finger  will  usually  i-eveal  a  soft- 
ness of  the  vaginal  portion  of  the  neck  of  the  uterus,  which  is  suggestive 
of  pregnancy;  and  the  bimanual  examination  will  show  that  the  uterus 
is  larger  and  somewhat  more  globidar  than  in  the  uuini]n'egnated  state: 
but  there  are  no  unfailiuG:  siu'us  which  will  indicate  with  absolute  accu- 


442  ^   SYSTEM  OF  LEGAL   MEDLCIXE. 

raer  tliat  pregnaucT  exists ;  tlie  s^-mi^toms  meutioned  may  all  be  due  to 
other  causes,  and  Ijoth  physician  and  patient  may  be  compelled  to  await 
fmther  developments  before  arriving  at  a  conclusion* 

A  sign,  called  after  its  discoverer  Hegar's  sign,  and  consisting  in  a 
bogginess  and  resiliency  of  the  lower  segment  of  the  body  of  the  uterus, 
is  discernible  from  the  fifth  to  the  seventh  week,  but  it  is  not  constant 
and  is  not  universally  recognized  as  a  sign  of  value.  The  sign  upon 
■wliich  the  wi-iter  places  gi'eatest  dei)endence  between  the  fifth  and  tenth 
weeks  is  the  discoloration  of  the  miicous  membrane  of  the  vulva  and 
vestibule.  This  varies  fi'om  a  pale  purple  to  a  pale  violet,  in  place  of 
the  light-piok  hue  of  the  unimpregnated  state.  It  implies  obstruction 
.of  the  venous  circulation  of  the  tissue  involved,  and,  while  it  may  be  an 
indication  of  obstruction  from  some  cause  apart  fi'om  pregnancy,  it  is 
of  gi'eat  value  in  detennuiing  a  diagnosis  when  taken  in  conjunction 
with  the  other  early  signs  of  the  pregnant  state.  It  is  the  first  sign 
which  arrests  the  attention  of  the  practiced  eye  in  making  an  inspection 
of  the  genitals.  It  has  been  observed  by  the  writer  in  hundi'eds  of  in- 
, stances  and  has  rarely  proved  misleading. 

From  the  second  month  of  pregnancy  onward  the  signs  ma}'  still  be 
.considered  with  advantage  from  a  subjective  and  an  objective  stand- 
point, the  foiiner  being  first  considered.  The  menses  continue  to  be 
wanting ;  the  breasts  continue  to  enlarge,  and  give  rise  to  more  or  less 
pain  and  soreness  •  nausea  and  vomiting  persist  until  the  fifth  or  sixth 
month  and  gradually  disappear  as  the  womb  rises  from  the  pelvis  into 
the  more  cax3aeious  aljdominal  ca^it}',  though  in  some  cases  tliej'  con- 
tinue until  the  end  of  pregnancy.  The  patient  has  uncontrollable  drow- 
siness and  sleeps  much  of  the  time,  also  backache,  vaginal  leucorrhea, 
frequent  uiclination  to  ui'inate,  and  other  annoyances ;  or,  on  the  other 
hand,  the  latter  poi-tion  of  j^regnancy  may  lie  free  from  discomfort,  or 
even  attended  liy  a  gi-eater  degree  of  comfort  than  is  customary  in  the 
imimpregnated  state.  One  of  the  most  important  of  the  subjective 
sjTnptoms  of  pregnancy  is  quicl'eriing,  which  is  a  peculiar  sensation,  some- 
times compared  to  the  fluttering  of  a  bu-d,  caused  by  the  movements  of 
the  fetus  within  the  womb,  and  the  first  intimation  to  the  mother  that 
;She  is  cariying  in  her  body  a  li^-ing,  moving  being. 

Of  the  objective  signs  the  discoloration  of  the  Aiilvar  mucous  mem- 
'brane  becomes  more  and  more  marked  as  gestation  progi-esses,  until, 
during  the  last  month,  the  color  may  be  ahnost  black.  In  some  eases 
the  veins  of  this  region  are  much  enlarged  and  resemlile  bimches  or 

*  Diekinson  (^Xeu-  York  Journal  of  Gynecology  and  Obstetrics,  November,  1893, 
p.  985)  offers  the  following  scheme  concerning" the  early  signs  of  pregnancy,  -which  is 
ihe  most  recent  contribution  to  the  subject : 

Six  sisms  of  early  pregnancy  obtained  by  the  bimanual  examination  : 

1.  Bellving  or  bulging  out  of  the  bodv  of  the  uterus.  1 

2.  Elasticity  or  bogginess  of  the  body  of  the  uterus.       ^^^^^^^  ^^^^,  ^^  .^  ^^^^^^ 
S.  Compressibility  of  the  lower  uterine  segment. 

4.  The  transverse  fold.  J 

5.  The  longitudinal  fold  or  furrow.    J  ^^^^^^^  ^^^  ^^  ^.^^  ^^^^^^ 

6.  The  denser  spot.  S  ^ 

Dickinson  thinks  that  in  favorable  cases  the  presence  or  absence  of  pregnancy  may 
be  determined  between  the  second  and  sixth  week  after  coitus,  or  between  the  third 
jind  eighth  after  the  beginning  of  the  last  menstruation. 


lilh'Tir,  SJ:.\,   I'HECSASCV,  AXD   DIlLll'ERY.  44;j 

clusters  of  worms.  The  softness  of  the  v;i<>ina  and  vaginal  portion  of 
the  neck  of  the  womb  also  ])ee()nies  more  pronouneed;  the  eervical  eaual 
])('c,omes  patulous,  readily  admittinj^'  the  end  of  the  index-fin, u'cr  as  the 
time  for  labor  ai)pr()aehes.  Tlie  enlargement  and  aseent  of  the  uterus 
])rogress,  pari  pas.sii,  with  the  development  of  gestation.  There  is  little 
(liffereuee  of  deseriptioii  among-  the  best  obstetrie  writers  concerning  the 
relations  of  the  uterus  to  its  surroundings  dur-ing  the  different  months 
ot  {)regnan('Y.  We  shall  follow  the  description  of  Winckel  {Text-hook  of 
Ob.sf ('fries,  1S90,  p.  79  et  seq.) : 

At  the  end  of  the  second  month  the  fundus  of  the  uterus  can  be  felt 
by  the  examining  hand  behind  the  sijiuplnjais  inihis. 

At  the  third  month  the  uterus  is  as  large  as  a  man's  fist,  and  the  ab- 
•donu^n  begins  to  be  prominent. 

At  the  fourth  month  the  fundus  of  the  uterus  has  risen  out  of  the 
pelvis. 

At  the  fifth  month  the  fundus  is  midway  between  the  symphysis  and 
the  navel.  StriaQ  l)egin  to  apjiear  upon  the  surface  of  the  abdomen,  and 
the  Tinea  aiha  assumes  anu)re  })igmented  appearance.  During  this  month 
the  sound  of  the  fetal  heart  may  be  detected  in  manj'  cases. 

At  the  sixth  montli  the  fundus  rises  to  a  point  about  two  iingers' 
breadth  below  the  navel,  and  its  lower  half  l)ecomes  flatter. 

At  the  seventh  month  the  fundus  is  two  fingers'  l)readth  above  the 
navel,  and-  during  this  montli  the  lower  pole  of  the  fetus  may  usually  be 
felt  through  the  vagina,  though  the  fetus  is  still  quite  movable  in  the 
fluid  in  which  it  floats. 

At  the  eighth  month  the  fundus  is  midway  between  the  navel  and  the 
epigastrium,  the  lateral  expansion  of  the  uterus  is  consideral)le,  and  the 
movements  of  the  child  are  very  vigorous  and  can  readily  be  felt  when 
the  hand  is  placed  upon  the  abdomen. 

During  the  ninth  nnnitli  the  fundus  nearly  reaches  the  epigastrium, 
continues  to  expand  laterally,  and  in  the  closing  weeks  of  pregnancy 
the  presenting  portion  of  the  fetus  descends  into  the  pelvis,  preparatory 
to  its  exit  from  the  birth  canal. 

In  addition  to  the  gradual  enlargement,  hardness,  and  soreness  of  the 
breasts  during  pregnancy,  an  important  point  to  be  observed  in  making 
a  diagnosis  is  the  enlargement  of  the  papilla3  or  sebaceous  glands  sur- 
rounding the  nipple,  also  the  greater  pronunence  of  the  idpple,  the  in- 
crease in  the  deposit  of  pigment  in  the  colored  areola  around  the  nipple, 
and  the  development  of  a  secondary  areola  around  the  first,  which  is 
lighter  in  color  and  narrower  than  the  first,  and  does  not  appear  until 
the  later  months  of  pregnancy.  Among  tlie  objective  signs  of  preg- 
nancy which  were  formerly  more  frequently  alluded  to  than  they  are  at 
the  present  time  may  be  mentioned  liesfein  and  halJoffenienf.  The  former 
was  first  brought  to  the  attention  of  the  profession  by  Nauche,  who 
asserted  that  its  presence  in  the  urine  was  a  cei'tain  sign  of  pregnancy ; 
it  (H)nsists  simply  of  tri})le  phosphates  and  low  forms  of  life — but  it  is 
also  found  in  the  urine  of  nudes  (Winckel,  Joe.  cif.).  It  has  frequeutl}^ 
been  referred  to  in  works  on  medical  jurispi'udence  as  a  diagnostic  sign. 
Ikdlottemenf,  which  consists  in  pressing  snuirtly  upon  the  fetus  with  a 
finger  in  the  vagina,  the  ball  of  the  finger  being  applied  to  the  anterior 
vaginal  wall,  the  pressin-e  causing  the  fetus  to  rise  in  the  fluid  in  wliicli 


444  ^   SYSTEM  OF  LEGAL  MEDICINE. 

it  is  immersed  and  then  rebound  against  tlie  finger,  is  a  good  enough 
sign,  but  not  always  practicable  nor  easily  accomplished.  Besides,  it  is- 
unnecessary  because  there  are  so  many  other  means  of  determining 
pregnancy  which  are  easier  of  application  and  jast  as  reliable.  The 
condition  of  the  kidneys  must  not  be  overlooked  in  determining  preg- 
nane}', especially  if  there  is  any  suspicion  that  disease  of  these  organs- 
existed  prior  to  ]3regnancy.  Frequent  examinations  of  the  urine  should 
be  made,  especially  with  reference  to  the  presence  of  albumin.  A  trace 
of  albumin  during  the  earlier  months  need  not  cause  alarm,  but  if,  after 
the  sixth  month,  when  there  is  more  or  less  pressure  from  the  uterus- 
upon  the  kidneys,  there  is  albumin  to  any  considerable  extent  in  the 
urine,  the  condition  becomes  one  of  grave  importance  and  calls  for  the 
most  careful  watchfulness  and  wisdom  on  the  part  of  the  physician. 
Eclampsia  or  convulsions  is  sometimes  associated  with  renal  disease 
during  the  latter  portion  of  pregnancy,  and  constitutes  one  of  the  most 
dangerous  complications  of  the  pregnant,  partiuient,  or  puerjDeral  state. 
There  are  no  peculiar  conditions  of  the  heart,  lungs,  intestines,  or  other 
viscera  during  pregnancy  which  call  for  particular  attention  in  a  book  of 
this  character.  The  systematic  treatises  on  obstetrics  may  be  consulted 
in  regard  to  all  such  unusual  incidents.  It  is  a  well-known  fact  that 
deceit  is  often  practiced  by  those  who  desire  to  be  pregnant,  as  well  as 
by  those  who  desire  to  be  relieved  of  pregnancy,  the  physician  being- 
often  imposed  upon  by  both.  Erroneous  diagnoses  are  made  by  physi- 
cians through  ignorance,  want  of  discrimination,  and  sometimes  on  ac- 
count of  difficulties  which  render  error  quite  pardonable.  Mistakes  of 
this  kind  are  far  less  frequent  than  formerly,  for  the  general  diffusion 
of  gynecological  knowledge  has  informed  the  profession  at  large  con- 
cerning the  anatomy  of  the  pelvis  to  a  far  greater  extent  than  ever 
before. 

Cases  which  simulate  pregnancy  may  be  divided  into  two  groups,  in 
the  first  of  which  enlargement  of  the  abdomen  will  be  the  chief  symp- 
tom, while  in  the  second  this  symptom  may  or  may  not  be  present,  other 
noteworthy  symptoms  being  prominent.  According  to  this  classification 
individuals  of  tbe  first-mentioned  variety  and  their  friends  may  be  de- 
ceived by  the  situation,  but  the  phj'^sician  usua,lly  will  not  be.  In  the- 
second  case  the  j)liysician  also  may  be  the  victim  of  deception. 

The  most  conspicuous  members  of  the  first  group  include  those 
women  with  whom  the  great  object  and  desire  of  life  is  to  become  preg- 
nant. This  group  also  includes  cases  which  are  interesting  and  impor- 
tant, and  in  which  the  entail  of  an  estate  depends  upon  the  birth  of  an 
heir.  The  intense  desire  of  these  women  to  have  children  very  often 
leads  them  to  imagine  that  they  are  pregnant  whether  there  is  any 
gi'ound  for  it  or  not.  A  famous  illustration  of  this  group  was  Queen 
Mary  of  England,  wife  of  Philip  II.  of  Spain,  who  was  continually  report- 
ing herself  pregnant,  and  even  appointing  the  time  for  her  accouchement. 
The  eidargement  of  the  abdomen  in  these  cases  is  usually  due  to  ferment- 
ative changes  in  the  intestines,  with  resulting  accumulation  of  gas  and 
such  gastric  aiul  intestinal  disturbance  as  is  not  an  uncommon  accom- 
paniment of  pregnancy.  The  distention  of  the  abdomen  from  this  cause 
may  continue  a  long  time,  and  a  woman  who  is  thus  affected  may  readily 
deceive  herself  with  the  thought  that  she  is  pregnant,  especially  if  she; 


BIRTH,  SEX,   niEGXANCY,  AND   DELIVERY.  445 

liappeiis  to  l)c  very  anxious  to  Ijoeoinc  so ;  aud  the  deception  is  fostered 
by  sympathizing-  friends  who  have  had  a  soniewliat  siniihir  experienee  in 
connection  with  their  own  pregnancies.  A  condition  of  this  cliai-acter 
slioukl  never  mislead  a  physician,  because  he  can  determine  by  examina- 
tion, with  the  aid  of  an  anesthetic  if  necessary,  whetiier  tlie  distention  is 
gaseous  or  due  to  an  enhirgement  of  the  uterus,  or  to  the  two  causes 
combined.  Collections  of  fluid  in  the  abdomen  nuiy  simulate  pregnancy. 
Such  collections  occur  in  connection  with  maligiumt  disease  of  the  al3- 
dominal  \dscera  or  with  tuberculosis  of  the  peritoneum.  This  condition 
sometimes  occurs  in  young  unnuirried  women,  and  the  unjust  suspicion 
which  is  aroused  is  peculiarly  cruel  l)y  adding  to  the  hardships  of  a  dis- 
ease which,  in  malignant  cases  at  least,  is  hopelessly  incuralile.  Enlarge- 
ment of  the  abdomen  due  to  the  presence  of  an  unusuall}^  aljundant 
deposit  of  fat  in  its  wall,  or  to  solid  or  fluid  tumors  in  its  cavity,  may 
simulate  pregnancy.  The  fii'st  of  these  statements  need  not  seem  in- 
credible, since  a  layer  of  abdominal  fat  three  or  four  inches  in  depth  is 
not  uncommon.  The  tumors  referred  to  have  mauy  tiines  been  mistaken 
by  the  uninitiated  as  evidence  of  pregnancy,  to  the  great  detriment  and 
unhappiness  of  those  ^\\\o  suffer  with  them.*  Before  the  time  when 
ovarian  tumors  were  well  understood,  those  who  had  them  were  often 
accused  of  pregnancy.  The  injustice  of  such  accusations  was  in  some 
notable  instances  demonstrated  by  the  removal  of  the  tumors  after 
death.  Happily  such  growths  are  now  removed  Avith  such  facility  and 
comparative  safety  that  an  innocent  w^oman  need  no  longer  suffer 
such  aspersions  until  her  veracity  can  be  attested  by  a  post-mortem 
examination. 

But  in  the  second  group  of  cases  mentioned  the  conditions  which 
simulate  pregnancy  may  be  of  such  a  character  as  to  deceive  even  the  ex- 
pert diagnostician  :  first,  when  the  uterus  alone  is  affected ;  second,  when 
the  diffi(;ulties  involve  other  organs  of  the  genital  aj)paratus.  The  uterus 
may  enlarge  slowly  aud  symmetrically  on  account  of  the  presence  of  a 
fibroid,  a  fibrocystic,  or  a  pnrely  malignant  growth,  the  enlargement 
being  strongly  suggestive  of  the  early  months  of  pregnancy.  A  single 
examination  may  leave  the  physician  in  doubt  as  to  the  existing  state  of 
affairs,  and  it  may  be  necessary  to  repeat  the  examination  several  times 
at  short  intervals.  A  spm-ious  pregnancy  in  the  form  of  a  mole  or  a 
hydatid  tumor  of  the  uterus  may  also  prove  misleading.  Cessation  of 
the  menses  from  any  of  the  causes  mentioned  in  the  remarks  concerning 
menstruation  (q.v.)  may  also  mislead  both  the  patient  and  the  physician. 
The  presence  of  milk  in  the  breasts  is  always  suggestive  of  the  pregnant 
state,  but  it  may  be  an  isolated  symptom. t  Softness  and  swelling  of  the 
vagina  and  cervix  and  external  genitals,  and  discoloration  of  the  vulvar 

*  It  imist  ho  remoinbeved  that  these  tumors  may  coexist  witli  pregnancy,  intro- 
ducing an  element  of  gva\'ity  which  may  be  very  serious. 

t  A  particuUirly  notewortliy  case  was  seen  by  the  writer  in  1891.  The  patient 
was  an  Irishwoman,  tliirty-one  years  of  age,  who  had  been  pregnant  but  once,  having 
borne  a  cliihl  Avlien  sixteen  years  of  age.  For  several  years  prior  to  ISOl  there  was 
milk  in  her  breasts,  and  for  the  two  years  immediately  preceding  it  was  constantly 
present,  as  much  as  a  tablesiioonful  being  frequently  removed  at  once.  She  had  suf- 
fered six  years  with  disease  of  the  pelvic  organs,  but  the  exact  relation  of  this  to  the 
active  condition  of  her  mammarv  glands  could  not  be  ascertained. 


446  ^   SYSTEM   OF  LEGAL  MEDICINE. 

mucous  membrane  caused  hj  interference  with  tlie  cii'culation  on  account 
of  neoplasms  in  the  ^^elvis,  may  make  it  difficult  or  impossible  to  affirm 
or  deny  the  existence  of  pregnancy. 

Multiple  pregnancy,  in  ^\'hich  two  or  even  tkree  fetuses  are  de\'eloped 
simultaneously,  is  sufficiently  well  known  as  a  physiological  fact.  King 
{Manual  of  Obstetrics,  1892,  p.  341)  states  that  twin  pregnancies  occur 
once  in  seventy-five  cases,  triplets  once  in  five  thousand,  and  that  quad- 
ruplets and  quintuplets  are  extremelj^  rare.  Winckel  behe^'es  that  fi^  e 
is  the  largest  number  of  fetuses  that  a  woman  can  sustain  in  her  uterus 
at  once,  and  that  the  statements,  especially  in  ancient  literature,  con- 
cerning women  who  have  had  more  than  five  infants  at  a  bii'th  are  fabu- 
lous. Well-authenticated  reports  of  quadruplet  and  quintuplet  bii-ths 
are  to  be  found  in  recent  literatiu"e.  (Winckel,  07;.  cit.,  p.  114.)  These 
multiple  pregnancies  may  result  from  one  ovum  which  has  undergone 
subdivision,  or  each  fetus  may  be  the  product  of  a  separate  ovum. 

Superfetation,  or  the  condition  in  which  fecundation  of  an  ovum  has 
taken  place  after  development  has  begun  in  an  ovum  in  the  same  uterus 
which  has  been  fecundated  at  an  earlier  period,  is  considered  a  possibil- 
ity, but  one  which  has  not  yet  been  proved.     In  the  condition  which  is 


/■  '^J 


Fig.  66.— Author's  case  of  double  uterus  (uterus  bicornis  unicoUis). ' 

known  as  double  uterus  (see  figures  and  history*),  in  which  there  are 
two  distinct  uterine  bodies,  union  of  the  two  having  failed  to  take  place 
during  fetal  life  in  accordance  with  the  usual  course  of  development, 
there  may  be  simultaneous  or  nearly  simultaneous  impregnation  in  each 

*  Antlwr's  Case  of  Double  Uterus. — The  patient  was  an  Irish"woman,  twenty-five 
years  of  age,  first  seen  August  15,  1889.  She  had  borne  five  children  Avithin  a  period 
of  five  years,  all  the  labors  having  been  tedious,  and  the  last  three  of  them  breech 
presentations.  She  had  had  no  miscarriages,  and  there  was  nothing  noteworthy  about 
her  menstrual  history.  The  vaginal  portion  of  the  cervix  uteri  was  very  large,  indu- 
rated, and  fissured,  the  uterus  retrofiexed  and  adherent.  There  were  large  external 
hemorrhoids  and  fissiire  of  the  aniis.  These  latter  difficulties  were  fii-st  operated  upon  ; 
then  Emmet's  operation  was  performed  upon  the  cerA-ix,  the  opei-ation  not  resulting 
satisfactorily.  Subsequently  the  cervix  was  ampiitated  and  the  ruptured  perineum 
closed,  the  result  being  good.  A  month  later  the  abdomen  was  opened  to  relieve  the 
adherent  uterus,  and  the  condition  found  which  is  represented  in  the  picture.  The 
round  ligament  of  each  uterus  was  shortened,  the  organ  being  thereby  brought  into 
its  normal  relations.  The  patient  recovered  without  mishap.  This  anomalous  condi- 
tion is  termed  by  Kussmaul  uterus  bicornis  unicoUis. 


BIETn,  SEX,  PREGNANCY,  AND   DELIVERY.  447 

cavity,  or  it  may  take  place  in  one  after  quite  an  interval  from  its  occur- 
rence in  the  other.  In  such  cases  one  of  the  children  niij^ht  be  born 
(lays  or  wet^ks  before  the  other.  It  is  even  possiljle  in  a  normal  uterus 
in  wliich  there  is  a  twin  pregnancy  that  development  may  not  proceed 
absolutely  puri  pussu^  and  that  one  fetus  may  mature  and  be  delivered 
somewhat  sooner  than  the  other,  the  supposition  being*  in  such  cases,  of 
course,  that  the  two  fetuses  are  in  two  separate  ova.  The  late  Dr.  For- 
dyce  Barker  repoi-ts  a  case  in  which  a  woman  gave  birth  to  a  child  from 
one  horn  of  a  double  uterus  July  10, 1855,  and  to  another  from  the  other 
horn  September  22,  1855.  Cases  are  recorded  in  wliich  black  women 
have  borne  twins,  one  of  them  Ijeing  black  and  the  other  white.  This  is 
probably  due,  as  Lusk  has  suggested,  to  the  detachment  of  two  ova  at 
the  same  menstrual  period,  and  to  coitus  with  a  black  man  and  also  with 
a  white  man  while  the  ova  were  still  in  the  uterus.  The  same  writer 
thinks  that  impregnation  at  two  periods  of  time  remote  from  each  other, 
in  the  same  uterus,  must  be  regarded  as  inadmissible  until  ph3'siologists 
shall  succeed  in  demonstrating  in  a  single  instance,  by  the  presence  of 
corpora  liitea  in  different  stages  of  development,  that  ovulation  ever 
occurs  during  pregnancy.* 

In  addition  to  the  peculiarities  which  are  involved  in  that  form  of 
pregnancy  which  has  just  been  considered  the  pregnant  state  is  suscejjti- 
ble  of  others  of  a  most  interesting  though  usually  \Qvy  grave  character. 
Allusion  is  made  to  the  so-called  ectopic  pregnancy,  in  which  the  o\T.im 
is  implanted  outside  the  cavity  of  the  uterus  and  usually  in  some  portion 
of  the  Fallopian  tube  (see  illustration  of  the  author's  case  of  tubal  preg- 
nancy, with  accompanying  history  t).  The  principal  facts  in  regard  to 
this  most  undesirable  method  of  fetal  development  have  ah-eady  been 
given  in  an  earlier  part  of  this  article,  and  ueed  not  be  repeated.  A 
number  of  cases  have  been  reported  in  which  K^iug  children  have  been 
I'emoved  through  an  incision  in  the  abdomen  after  having  developed  in 
this  abnormal  manner ;  but  they  have  been  defective  and  short-lived  in 
alinost  all  cases.  What  is  stiU  more  strange,  there  are  cases  on  record 
in  which  two  fetuses  have  been  found  in  the  same  tube,  in  different  stages 
of  development ;  also  cases  with  one  fetus  in  each  tube,  and  others  with 
one  fetus  in  a  tube  and  another  where  it  belonged,  in  the  cavity  of  the 
uterus.  Such  facts  are  quite  in  the  i-ealm  of  the  marvelous,  and  impi-ess 
us  with  wonder  at  the  eccentricities  of  which  natvu'e  is  capable. 

The  advent  of  puberty  in  the  female  is,  as  w'e  have  seen,  usually  re- 
garded as  the  announcement  that  conception  is  now  a  possibility.  The 
age  at  which  this  occurs,  as  well  as  the  age  when  the  child-bearing  func- 

*  Obsteti'ic'ians  of  tlie  liigliest  authority  admit  the  existence  of  superfetation  in 
animals.  Schroeder  narrates  a  numher  of  such  cases  (Lchrbuch  dcr  GchurtsJiiilfc,  ISSO, 
]).  7(5) ;  hut  tlie  same  high  authority,  with  Kleinwachter,  Lelshman,  Seanzoni.  Wagner, 
liamsbotham,  and  Churchill,  all  concur  in  denying  the  existence  of  any  reliable  evi- 
dence, thus  far,  that  superfetation  ever  occurs  in  women. 

t  A  recent  case  of  the  writer's,  a  drawing  of  wliich  is  given  herewith,  illustrates 
in  a  general  way  the  condition  of  tubal  pre,gnancy.  This  case  was  that  of  a  negro 
woman  thirty-three  years  of  age,  who  had  given  birth  to  one  child  twelve  years  ago 
(1882).  She  had  been  complaining  for  some  weeks  jirior  to  operation,  which  was 
performed  February  12,  1894,  but  pregnancy  was  not  suspected.  The  tumor  A  repre- 
sented the  results  of  pregnancy.  It  was  as  large  as  a  hen's  egg,  and  was  intiniately 
associated  with  the  tumor  B,  both  tumors  containing  much  blood  and  blood-clot.     No 


448  ^   SYSTEM  OF  LEGAL  MEDICINE. 

tiou  ceases,  is,  as  we  have  also  seen,  variable,  depending  upon  climate, 
race  and  family  pecnliarities,  and  other  well-known  conditions.  In  tem- 
perate climates  pregnancy  rarely  occurs  earlier  than  the  sixteenth  or 
later  than  the  forty-fifth  year.    In  tropical  climates  women  mature  early 


o      \  /  V  \b 


/ 


/      \  / 


Fig.  67.— Author's  case  of  tubal  pregnancy.  The  structures  are  seen  in  front  or  face  view. 
V.  Vagina;  A^  o,  left  Fallopian  tube,  with  tumor  of  pregnancy  at  A ;  B,  tumor  of  left  ovary; 
F,  normal  right  Fallopian  tube ;  O,  normal  right  ovary. 

and  the  child-bearing  function  ceases  early.  Among  the  savages  of  New 
Mexico  and  Arizona  (Mojaves,  Apaches)  complete  womanly  development 
is  often  seen  as  eavlj  as  the  twelfth  year.  Among  the  Arabs  of  the 
desert  the  child-bearing  period  is  said  to  end  frequently  as  early  as  the 
twentieth  year  or  soon  thereafter. 

In  cold  climates  puberty  is  delayed.  Among  the  Esquimaux,  as  well 
as  among  the  northern  Swedes  and  Norwegians,  it  is  often  delayed  until 
the  eighteenth  or  twentieth  year,  the  child-bearing  function  ceasing 
early  from  the  same  cause  which  delays  puberty.  Winckel  is  authority 
for  the  statement  that  in  Germany  the  power  of  reproduction  is  estab- 
lished from  the  thirteenth  to  the  fifteenth  year.  In  India,  with  its  warm 
climate  and  its  pernicious  system  of  child-marriages,  early  menstruation 
and  conception  are  common,  the  latter  sometimes  occurring  as  early 
as  the  tenth  year.  Even  in  New  York  City,  Barker  has  seen  conception 
at  the  tenth  year,  and  I.  E.  Taylor  at  the  twelfth.  The  writer  has  seen 
it  a  number  of  times  at  the  fourteenth  year.     At  the  other  extreme, 

fetus  was  found  in  tumor  A,  but  placental  structure  was  shown  by  microscopical  ex- 
amination made  by  three  expert  microscopists.  The  fetus  probably  died  at  a  very 
early  period  and  was  quickly  absorbed,  the  other  structin-es  retaining  their  vitality, 
and  hemorrhasce  had  probably  taken  place  on  several  occasions.  Both  ovaries  and 
tubes  were  removed,  the  woman  making  an  uneventful  recovery. 


BIRTH,  SEX,  rilEGXAXCY,  AXD   DELIVERY.  '         449 

Barker  has  seen  a  first  preg-nancy  as  late  as  the  fifty-second  year,  fol- 
Icjwed  by  a  second  and  a  third  in  the  same  person  at  the  fifty-third  and 
fifty-fifth  years.  He  thinks  this  the  hitest  period  of  Avhich  there  is  any 
authentic  record  of  such  an  occurrence,  with  the  exception  of  that  of 
8arah  whicli  is  mentioned  in  the  Book  of  Genesis*  {Tr<iiisarfio)is  Amer- 
ican (jj/iitroI<)(jic(il  >S<>ci<'fij,  1S88,  p.  301.)  Legrand  dn  >S;nil]e  (Mf'd&rine 
Jjfgnle,  second  edition)  states,  without  referring  to  j)articular  cases,  that 
pregnancy  may  occur  as  hite  as  the  seventieth  year. 

Tlie  question  as  to  the  possible  existence  of  pregnancy  without  the 
knowledge  or  consciousness  of  the  woman  may  be  regarded  from  differ- 
ent standi)oints.  We  must  consider  not  onl}^  the  facts  relating  to  the 
woman's  physical  condition,  l)ut  also  the  very  important  question  of  lier 
truthfulness.  It  is  undenial)le  that  many  women,  especially-  the  young 
and  unmarried,  unblushingiy  refuse  to  admit  the  possibilit}'  of  preg- 
nancy from  its  beginning  to  its  termination,  and  it  may  be  impossible  to 
decide  whether  this  is  due  to  their  untruthfulness  or  to  their  unconscious- 
ness of  their  condition.  The  deception  or  attempt  to  deceive  must  ulti- 
mately be  exposed.  In  other  cases,  in  which  conception  has  taken  place 
without  the  introduction  of  the  penis  into  the  vagina,  in  Avliich  the  hymen 
is  practically  intact,  it  is  easy  to  understand  the  unwillingness  on  the 
part  of  the  woman  to  believe  that  she  can  be  pregnant.  In  cases  in 
which  coitus  has  taken  place  during  sleep  or  intoxication  or  the  hypnotic 
state,  self-deception  is  also  possible.  There  is  also  the  class  of  cases 
associated  with  uterine  or  ovarian  tumors,  in  which  pregnancy  has  super- 
vened after  the  existence  of  the  tumor  was  recognized.  The  writer  has 
seen  such  a  case  in  which  pregnancy  was  unsuspected  until  labor  actually 
began.  Again,  there  is  the  entire  class  of  extra-uterine  pregnancies,  in 
which  the  condition  may  not  be  suspected  until  the  abdomen  is  opened 
by  the  surgeon  for  the  purpose  of  removing  a  tumor  the  character  of 
which  he  might  be  quite  unable  to  determine  in  advance  or  until  the 
situation  is  determined  by  autopsy.  In  a  case  which  has  been  reported 
by  the  writer,  a  woman  was  luider  the  constant  supervision  of  an  acute 
and  unusually  inteUigent  physician  for  weeks  before  her  death.  The 
latter  event  took  place  suddenly,  after  symptoms  of  great  abdominal  dis- 
turbance accompanied  with  agonizing  pain.  An  a-utops}'  was  nuide,  and 
when  the  abdomen  was  opened  an  infant,  nearly  full- grown,  was  found 
lying  free  in  the  abdominal  cavity,  where  it  had  developed  entirely  out- 
side the  uterus.  Normal  pregnancy  has  many  times  been  mistaken  even 
by  the  expert  gynecologist  for  a  tumor  which  required  removal,  the  true 
situation  becoming  known  only  when  the  abdomen  Avas  opened. t     From 

*  The  writer  has  been  informed  of  a  case  which  was  known  to  one  of  his  associates 
(Dr.  G.  W.  Smallwood),  in  which  delivery  of  a  living  child  took  place  when  the  mother 
was  sixty  years  of  age,  fourteen  years  after  the  menopause  was  supposed  to  have  oc- 
ciirred.  Such  cases  demonstrate  the  persistency  of  ovulation  beyond  the  limit  which 
has  usually  l)een  fixed  for  that  event. 

t  Three  such  cases  have  occurred  in  the  writer's  practice  in  recent  years.  lu  one, 
the  wife  of  a  physician,  long  under  the  writer's  observation,  presented  all  the  char- 
acteristic sjanptoms  of  tubal  pregnancy.  The  ■SATiter's  diagnosis  was  conctirred  in  by 
a  eolleagtie  of  great  experience.  The  abdomen  was  opened  and  the  uterus  foimd  dis- 
placed, but  with  the  fetus  within  it  and  not  outside  of  it.  An  abortion  followed  on 
tlie  third  day,  and  deatli  from  peritonitis  several  days  later.  In  the  second  case  there 
was  disease  of  the  ovaries,  but  tlie  pregnancy  was  not  recognized  until  tlie  abdomen 
^as  opened.     The  patient  recovered  without  abortion.     In  the  third  ease,  a  S\-i-ian 


450  -=i  STSTi::ii  of  legal  mediclxe. 

the  foregoing  it  ^viR  be  evident  that  it  is  qnite  possible  for  a  -woman  ta 
be  ignorant  of  the  fact  that  she  is  pregUcint,  or  to  be  conscious  that  she 
is  pregnant  and  be  able  to  snccessf  ally  decei^'e  the  phvsician  without 
disparagement  to  his  skill  and  discrimination. 

Viability  is  the  term  which  is  applied  to  the  susceptibility  of  an  in- 
fant to  sustain  existence  outside  its  mothers  womb.  It  impHes  a  degTee 
of  development  sufficienth'  advanced  to  sustain  such  an  existence.  A 
child  is  not  mature  or  ripe  until  the  normal  termination  of  "pregnancy, 
but  it  is  frequently  capable  of  living  and  developing  though  born  prior 
to  maturity.  Premature  ehildi-en  are  of  course  more  sensitive  and  deli- 
cate than  those  who  have  reached  fiUl  matiu-ity.  but  there  are  countless 
instances  in  which  such  children  have  surmounted  such  adverse  condi- 
tions and  lived  to  adult  life  or  old  age.  The  seventh  month  has  usually 
been  regarded  as  the  earliest  hmit  of  fetal  viabiUty.  and  many  who  are 
born  at  that  early  period  quickly  succumb.  The  vital  organs  are  suffi- 
ciently developed  to  permit  the  continuance  of  life,  but  unless  the  sui-- 
roundings  are  unusually  favorable  attempts  to  rear  such  feeble  infants 
are  usually  futile.  In  recent  years,  and  especially  in  France,  the  use  of 
the  couveme  or  incubator  has  resulted  in  the  sa^ing  of  many  prematiu-e 
or  iinmatui-e  children.  The  names  of  Tarnier  and  Auvard  are  promi- 
nently identified  with  this  important  work,  and  Auvard  beheves  that  by 
the  judicious  use  of  the  incubator  the  limit  of  vialiility  may  be  set  back 
as  early  as  the  end  of  the  sixth  inonth.  The  question  of  successfully 
continuing  existence  is  quite  different  from  that  of  merely  showing  signs 
of  animation,  such  as  gasping,  mo^dng  the  limbs  or  even  the  body. 
Children  who  give  such  signs  of  life  are  qnicTi  or  li-sdng,  in  distinction 
from  the  stiU-born,  who  give  no  e-^T-dence  whatever  of  life.  Signs  of  life, 
though  few  and  feeble,  may  be  of  the  gTcatest  impoi-tance  from  a  legal 
standpoint.  Cases  are  not  infrequent,  especially  in  the  gynecological 
literature  of  the  past  few  years,  in  which  signs  of  Life  have  been  shown 
at  the  sixth,  fifth,  or  even  fourth  month.* 

Tlie  absolute  duration  of  gestation — that  is.  the  exact  time  from  con- 
ception to  dehvery — is,  for  many  reasons,  a  diifieiilt  matter  to  determine 
in  the  great  majority  of  instances.  If  a  woman  experiences  sexual  inter- 
course ever}^  day  or' nearly  every  day  it  will  be  almost  impossible  in  case 
of  pregnancy  to  decide  just  when  conception  occuiTed.  If  sexual  inter- 
unable  to  speak  Euglisli,  the  tumor  was  supposed  to  l3e  one  reqtiiring  extii-pation  of 
the  uterus.  The  preguauey  was  recognized  when  the  abdomen  was  opened,  and  the 
patient  prompt!}"  recovered,  also  without  abortion. 

In  another  case  kno\^^l  to  the  wi-iter  a  siu'geon  of  great  experience  opened  the  ab- 
domen on  account  of  supposed  ovarian  tumor,  mistook  the  pregnant  uterus  for  such 
a  tumor,  thrust  a  trocar  into  it,  and  only  then  discovered  his  error.  This  patient  also- 
recovered,  and,  it  is  believed,  without  abortion. 

*  Coe's  case  of  extra-uterine  pregnancy,  which  was  recently  reported,  is  a  verr 
remarkable  one.  The  fetus  was  said  to  be  between  three  and  four  months  old.  and 
after  it  had  been  removed  from  the  mother's  abdomen  "  it  made  vigorous  movements 
of  the  arms  and  legs  for  at  least  three  or  four  minutes,  which  were  observed  by  several 
spectators."     {Tran.mctious  American  Gi/necoloffical  Sncicti/,  1S93.  p.  271.) 

In  Lusk's  case  of  extra-uterine  fetation  the  infant  was  well  advanced  in  the  sixth 
month.  It  lived  twenty-six  minutes  after  delivery  from  the  mothers  abdomen.  It 
was  between  eleven  and  twelve  inches  in  length,  weighed  twenty-fo^ir  ounces,  had 
fine  hair  upon  its  head,  fat  in  the  cellular  tissue,  but  no  lanugo  or  vernix  caseosa. 
The  eyelids  were  separate  and  the  pupillary  membrane  stiU  distinct.  The  nails  did 
not  reach  to  the  tips  of  the  fingers.     {Traits.  Amer.  Gi/n.  Soc,  1893,  p.  263.) 


BIRTH,  tSEX,   I'L'EGXJSCy,  AXD   DELIVEUY.  4,31 

course  occnirs  only  at  considerable  intervals  the  date  of  etjiieeption  ma}' 
be  more  ncai-ly  ai>proxiniated.  If  ovulation  invai-iably  coincided  -with 
menstruation,  and  occurred  at  no  otlier  time,  the  solution  of  the  question 
would  be  facilitated.  Some  Avritci-s  are  of  the  opinion  that  ovulation 
may  occur  at  any  and  all  times,  irrespective  of  menstruation :  if  this  i^; 
correct  the  hal)it  of  dating-  conception  from  the  last  menstruation  is  un- 
reliable. Even  if  the  last  coitus  for  a  long  period  of  time  were  assumed 
to  be  the  fruitful  one  there  would  still  be  a  chance  of  error,  for  the  reason 
that  a  previous  coitus  might  have  been  the  fruitful  one.  If  the  last  coitus 
were  fruitful  the  exact  date  woidd  still  be  uncertain,  on  account  of  the 
uncertainty  as  to  the  (XMnu-rence  of  ovulation,  and  also  as  to  the  activity 
and  vitality  of  the  sj^ernuitozoa.  The  microscope  has  shown  that  this 
vitality  nuiy  continue  as  numy  as  eight  days,  and  as  long  as  active  mo- 
tion is  apparent  they  are  capable-  of  performing  their  function  in  fructi- 
fying the  ova.  None  know  better  than  the  obstetrician  that  the  habit  of 
fixing  dates  for  conception  and  labor  is  unti'ustworthy,  for  none  suffer 
more  annoyance  and  inconvenience  as  the  result  of  such  miscalculation. 
It  is  merely  a  method  of  guessing,  for  the  premises  upon  which  to  base 
mathenuitically  accurate  calculations  are  wanting.  The  development  of 
the  fetus  in  nfero  may  be  influenced  by  the  same  causes  which  influence 
puberty  and  menstruation,  though  of  course  not  to  the  same  extent. 
Such  conditions  are  climate,  race  and  family  pecuKarities,  the  general 
state  of  body  aud  mind  of  the  mother  during  the  period  of  gestation,  etc. 
The  statements  which  women  make  concerning  the  data  of  theu*  preg- 
nancies are  not  always  to  be  relied  upon,  however  timthful  the  intention 
of  the  individual  may  be. 

J.  Veit  (quoted  by  Wiuckel,  he.  cif.)  observed  the  following  variations 
in  the  duration  of  pregnancies  in  the  same  series  of  women : 

In  7  eases  the  variation  was  less  than  10  days. 
"  4  "  "  "    from  10  to  20     " 

"  7  "  "  "    fi-ora20to40     " 

"  2  "  "  "    more  than  40     " 

"  1  case  "  "  64     " 

Schlichting,  also  quoted  by  Winckel,  observed  in  456  cases  that  the  dura- 
tion of  pregnancy  varied  from  240  to  334  days. 

Of  several  observers  who  have  started  from  a  common  basis,  their  in- 
formation l.)eing  assumed  to  be  relialjle,  and  the  basis  being  that  the 
ovum  of  the  last  menstruation  is  impregnated,  the  duration  of  pregnancy 
being  calculated  from  the  flrst  day  of  that  period : 

Mattei  found  the  average  duration 265       days. 

Schlichting  found  the  average  duration 273.1        " 

Matthews  Duncan  foimd  the  average  duration 278  " 

Waehs,  Jr.,  found  tlie  average  duration 279.87     " 

Lowenliardt-Ahlfeld  foiuid  the  average  dui'ation 281.6       " 

Winckel  {op.  cif.,  p.  94)  made  a  careful  study  of  more  than  5000  cases 
of  pregnancy  in  order  to  give  expert  testimony  in  regard  to  its  dm-ation 
before  a  German  court.  In  70  of  these  cases  the  duration  exceeded  300 
days,  and  in  47  it  exceeded  302.  In  one  it  was  314,  and  in  another  318, 
days  from  the  day  of  the  presumably  effective  coitus  to  the  day  of  de- 
livery.    The  conclusion  of  Winckel  is  in  the  following  words :    "  The 


452  ^   SYSTEM  OF  LEGAL  MEDICINE. 

average  duration  of  pregnancy  is  abont  280  days ;  it  may  vary,  liowever, 
from  24-0  to  320,  and  perhaps  even  exceed  this  latter  limit,  which  is  by 
no  means  so  rare  as  was  formerly  supposed,  for  in  6.8  percent,  the  dura- 
tion is  over  300  days." 

Sclu'oeder  wisely  says  that  a  very  large  child,  with  evidences  of  un- 
usual development,  vigorous  voice,  large  frame,  long  liau',  etc.,  does  not 
necessarily  mean  an  unusually  prolonged  gestation,  for  all  these  phe- 
nomena may  be  seen  in  immature  children. 

Winckel  narrates  a  case  in  which  310  days  intervened  between  the  last 
coitus  and  the  birth  of  the  child.  The  mother  had  been  divorced  from 
her  husband  on  account  of  adulter}^,  and  additional  punishment  was 
sought  by  the  husband  by  civil  process.  The  possibility  that  the  dura- 
tion of  pregnancy,  under  lawful  conditions,  was  310  days  could  not  be 
disproved,  and  this  fact,  together  with  the  very  large  size  of  the  child, 
led  to  the  mother's  acquittal. 

Protracted  gestation  exceeding  even  the  limit  mentioned  in  the  fore- 
going statements  may  occur  either  in  the  intra-uterine  or  extra-uterine 
variety.  In  the  former  variety  some  unusual  conditions  may  have 
caused  the  delay,  such  as  abnormal  rigidity  of  the  uterus,  undue  absence 
of  irritability  in  the  uterus,  absorption  of  the  liquor  amnii,  or  disease 
and  death  of  the  fetus.  If  labor  does  not  occur  within  a  short  time  after 
the  fetus  has  reached  maturity  its  death  must  follow  as  a  consequence, 
and  in  this  condition  it  is  possible  that  it  miglit  be  retained  weeks  or 
months,  perhaps  undergoing  decomposition,  or  withering  and  shriveling 
without  decomposition,  or  becoming  converted  into  a  hard,  stone-like 
mass,  called  lithopa^dion  from  the  abundant  deposit  of  lime  salts  within 
its  tissues.  An  inert  mass  of  this  character  may  be  carried  by  a  woman 
in  her  uterus  for  the  remainder  of  her  life,  it  may  be  delivered  sponta- 
neously, or  its  delivery  may  be  brought  about  by  the  efforts  of  the  physi- 
cian.  The  last-mentioned  course  is  always  proper,  and  should  be  resorted 
to  as  soon  as  it  is  definitely  determined  that  the  child  is  dead. 

If  the  pregnancy  is  of  the  extra-uterine  variety  and  should  continue 
until  term,  that  is,  until  the  fetus  is  perfectly  mature,  false  labor-pains 
may  be  experienced  at  that  time.  They  are  false  because  they  do  not 
occur  in  a  uterus  which  is  pregnant,  and  because  delivery  by  the  natiu-al 
avenues  and  means  is  impossible.  Death  of  the  mother  may  result  from 
hemorrhage,  or  from  septiceemia  (blood-poisoning)  in  connection  with  the 
decomposition  of  the  child,  or  she  may  have  vitality  sufficient  to  with- 
stand these  or  any  other  accidents  in  this  connection  and  die  eventually 
from  some  entirely  different  cause.  The  child  may  be  converted  into  a 
lithop^dion,  which  was  described  in  the  preceding  paragraph ;  it  may 
decompose  and  the  firmer  tissues  eventually  be  discharged  after  ^^lcera- 
tion  into  the  rectum,  the  vagina,  or  the  bladder ;  or  it  may  be  removed 
from  the  abdomen  by  surgical  operation.  Cases  which  illustrate  all 
these  possible  consequences  are  recorded  in  recent  gynecological  lit- 
erature. 

The  duration  of  pregnancy  is  insufficient  when  labor  occurs  before  the 
fetus  has  reached  maturity.  This  does  not  imply  that  a  living  child  may 
not  be  born  and  be  susceptible  of  development  though  it  may  be  imma- 
ture in  many  respects.  The  facts  which  relate  to  this  phase  of  the  ques- 
tion have  been  considered  in  connection  with  viability,  and  the  subject 
will  be  further  discussed  in  the  article  on  Abortion  (q.v.). 


BIETH,  SEX,  rilEGXAXVY,  AM)   DELIVERY.  453 

The  deterniiuation  of  the  period  of  pregnancy  which  has  lieen  reached 
in  such  eases  is  by  referenc'e  to  tlie  hist  menstruation  or  l)y  inspection  of 
the  fetus  itself. 

The  question  of  legitimacy  of  offspring  must  in  many  cases  hinge  upon 
the  supposed  dui-atiou  of  pregnancy,  and  it  has  been  shown  that  this  is 
a  subject  in  which  error  is  very  liable  to  occur.  Many  States  liave  fixed 
legal  limits  to  the  duration  of  pregnancy,  but  it  must  be  evident  from 
the  testimony  which  has  been  adduced  that  such  limits  are  very  fallible, 
and  that  adherence  to  them  provides  the  opportunity  for  possible  injus- 
tice. By  Scottish  laAV  and  bv  the  French  Code  300  days  is  the  legal  limit 
allowed  for  pregnancy ;  by  Prussian  law  the  limit  is  301  days  (note  as 
exception  the  case  quoted  by  Winckel  in  a  previous  paragraph).  By 
English  law  no  time-limit  for  pregnane}'  is  fixed,  cases  being  decided  in 
accordance  with  the  evidence  of  medical  experts  and  the  moral  and  col- 
lateral aspects  of  each  case.  In  this  country  great  latitude  is  allowed. 
Two  cases  are  quoted  by  Taylor,  in  both  of  which  legitiinac}^  was  ad- 
mitted, the  diu-ation  of  pregnancy,  counting  from  the  last  coitus,  being 
313  days  in  one  and  317  in  the  other.  (See  Leishman's  System  of  Mid- 
^vifenJ,  1875,  p.  181.)  As  it  has  been  shown  to  be  impossible  to  deter- 
mine with  accuracy  the  exact  dm-ation  of  completed  pregnancy  in  any 
given  case,  this  being  a  variable  quantity,  it  may  be  shown  to  be  equally 
impossible  to  state  Avith  exactness  the  point  or  extent  of  development 
which  has  been  reached  in  any  given  case  of  incomplete  pregnancy.  It  is 
quite  possible,  however,  to  answer  such  a  question  approximately,  and  thus 
satisfy  all  legal  requii-ements.  Reference  to  the  last  menstruation  will 
usually  be  regarded  as  the  most  important  limit  from  which  to  make  the 
necessary  calculations.  The  size  of  the  uterus  will  also  be  of  assistance 
in  such  calculations,  and  we  may  add,  upon  this  point,  to  the  suggestions 
alread}^  given,  the  convenient  statements  of  Lusk,  which  are  as  follows : 
In  the  second  month  the  uterus  is  as  large  as  an  orange ;  in  the  third  it 
is  as  large  as  a  child's  head ;  in  the  fourth  it  is  as  large  as  a  man's  head 
and  can  be  felt  above  the  stjmjyJu/sis  ^>»&/s;  in  the  fifth  the  fundus  is  mid- 
way between  the  sj^mphj^sis  and  navel ;  in  the  sixth  it  has  reached  the 
navel ;  in  the  seventh  it  is  two  fingers'  breadth  above  the  navel ;  in  the 
eighth  it  is  half-way  between  the  navel  and  the  epigastrium ;  in  the  ninth 
it  reaches  the  epigastriimi ;  in  the  tenth  (lunar  months  are  considered) 
it  sinks  until  its  upper  level  corresponds  with  the  situation  at  the  eighth. 
(See  cut  from  Lusk's  Science  cind  Ati  of  Midivifenj,  p.  113.)  As  the 
navel  is  not  a  fixed  point  and  varies  considerably  in  different  women  in 
its  distance  from  the  symphysis,  Spiegelberg  suggests  that  measurements 
be  made  from  the  SYmi)hysis  as  a  constant  limit.  Lusk  adds,  however, 
that  it  must  be  remembered  that  the  uterus  is  subject  to  variations  ac- 
cording to  the  size  of  the  child  and  the  quantity  of  amniotic  fluid.  Spie- 
gelberg's  measurements  from  the  symphysis  to  the  fundus  at  different 
periods  are  as  follows : 

From  the  22d  to  the  2Gth  week 8^  inches. 

From  the  2'2d  to  the  28th  week lOi  " 

From  tlie  22d  to  tlie  30th  week ll"  " 

From  the  22a  to  the  32(1  and  33d  week. .  lU  " 

From  the  22d  to  the  34th  Aveek 12"  " 

From  the  22d  to  the  3oth  and  36th  week  12i  " 

From  the  22d  to  tlie  37th  and  38th  week  13'  " 

From  the  22d  to  the  39th  and  40tli  week  13i  " 


454 


A  SYSTEM  OF  LEGAL  MEDICINE. 


AMf eld,  whose  work  on  the  determination  of  the  size  and  age  of  the  fetus 
prior  to  birth  {ArcMv  fiir  Gi/ndJcoIogie,  Band  ii.,  p.  353)  is  authority  with 
the  best  recent  obstetrical  authors  (Schroeder,  Wiuckel,  Lusk,  et  al.), 
adopts  methods  which  are  rather  complicated  for  general  use,  and  Lusk's 


Fig.  68. 


-Schultze's  diagram,  illustrating  schematically  the  enlargem.ent  of  the  ntems 
during  the  successive  months  of  pregnancy.     (Lusk.) 


criticism  of  them  is  that  they  show  such  variations  in  the  size  of  children 
born  in  the  same  week  of  pregnancy  as  to  somewhat  impair  theu*  prac- 
tical vahie.  Additional  assistance  in  determining  the  period  of  gestation 
may  be  derived  by  reference  to  the  date  of  quickening.  This  is  said  to 
occur  usually  at  the  eighteenth  week  of  pregnancy,  but  allowance  must 
always  be  made  for  variations  from  that  limit. 

The  measurements  of  Fan*e  are  regarded  by  many  as  very  valuable, 
and  differ  from  those  which  have  been  given  by  Spiegelberg.  They 
would,  perhaps,  be  seldom  applicable  upon  the  living  subject ;  neverthe- 
less they  demonstrate  the  impossibility,  even  on  the  part  of  competent 
anatomists,  of  arriving  at  identical  results  upon  such  a  question  as  this. 
The  following  are  Farre's  measurements  of  the  pregnant  uterus : 


BIliTH,  HEX,   riiKCXAyCY,  AM)   DELIVERY.  455 


Length, 

Width, 

Inches. 

Inches. 

3d  montl 

1  4 A  to  5 

4 

4th       " 

H    "  6 

5 

5th       " 

6      "7 

5A 

Gth       " 

8      "9 

H 

7t]i       " 

10 

H 

8tli       " 

11 

8 

9th       " 

12 

9 

If  after  the  foregoing  rules  have  been  applied  the  utmost  limit  of  ges- 
tation has  been  reached  and  no  signs  of  labor  are  ajjparent,  the  suspicion 
will  be  warrantable  that  there  is  exti"i-uterine  gestation,  or  that  there  is 
intra-uterine  gestation  and  that  the  fetus  has  died.  The  former  supposi- 
tion will  be  warrantable  if  a  sound  introduced  into  the  uterus  shows 
that  the  organ  is  only  slightly  enlarged  if  enlarged  at  all.  If  the  latter 
supposition  is  the  correct  one  there  will  be  absence  of  fetal  movement ; 
palpation  of  the  uterus  wiU  show  want  of  resiliency  in  the  organ,  and  a 
sensation  of  bogginess  or  doughiness,  while  the  patient  will  be  conscious 
■of  an  unconifortal)k^  feeling  of  weight  or  chilliness  in  the  uterus,  which 
is  very  diifereiit  from  the  sensation  which  is  produced  by  the  presence 
•of  a  living  cliild. 


IV,   DELIVERY. 

Delivery  and  the  Puerperal  State — The  Condition  of  the  Genital  Organs  at 
the  Time  of  DeKreri/,  together  tvith  Evidences  in  General  of  Recent  De- 
livery— Lorhial  and  Lacteal  Secretions — Supposititious  and  Suppressed 
Children — Feigned  Delivery — Duties  of  the  Physician  when  the  Conse- 
quences of  Labor  are  LiJiely  to  Prove  Serious  to  Mother  or  Child — Inter- 
vals between  Successive  Pregnancies — Evidences  that  Pregnancy  has 
Existed  at  any  Time — The  Injuries  of  Parturition,  their  Frequency, 
Extent,  and  Possible  Consequences — Duty  of  the  Obstetrician  in  Recog- 
nizing and  Treating  Them — Responsibility  of  the  Patient  when  the  Physi- 
cian's Adviceis  not  Heeded — Questions  Concerning  the  Duties  of  Physiciayis 
in  the  Presence  of  Conditions  which  Call  for  the  Major  Operations  in 
Obstetric  Surgery. 

Delivery  or  labor  or  parturition  includes  the  phenomena  associated 
with  the  extrusion  of  the  fetus  and  the  structures  appertaining  to  it 
through  the  birth  canal.  It  is  divisible  into  three  distinct  stages  or  peri- 
ods, the  first  being  concerned  with  the  softening  and  dilatation  of  the 
tissues  throngli  wliich  the  fetus  is  to  pass,  the  second  with  the  passage 
outward  of  the  fetus,  and  the  third  with  the  expulsion  of  the  placenta  or 
fleshy  structure  which  has  been  the  bond  of  union  between  the  mother 
and  the  child,  the  medium  through  which  the  \'ital  cm-rent,  with  its 
nutrient  elements,  has  been  comnumicated  from  the  one  to  the  other. 
With  the  placenta  are  also  expelled  the  membranes  or  envelopes  in 
wliich  the  fetus  has  been  suri'ounded. 

Delivery  at  term  signifies  com])letion  of  development — the  fruit,  being 
ripe,  drops,  having  no  further  necessity  for  attachment  to  the  parent 
stem.     If  labor  occurs  before  the  fetus  has  matured  it  means,  as  in  the 


456  ^   SYSTEM  OF  LEGAL  MEDICINE. 

analogous  condition  in  vegetable  life,  unripeness  and  imperfection,  with, 
possiljle  harm  to  the  stem  from  which  it  has  been  separated. 

Deliver}'-,  like  pregnancy,  is  a  normal  function,  and  when  accomplished 
in  a  perfectly  normal  manner  should  give  rise  to  no  serious  disturbance. 
Among  many  of  our  native  Indian  tribes  the  pain  and  discomfort  asso- 
ciated with  labor  are  insignificant.  A  woman  may  fall  in  labor  while  on 
the  march :  she  stops  awhile  until  the  child  is  born,  washes  it  in  the  near- 
est stream,  straps  it  on  her  back,  and  then  hurries  forward  to  rejoin  her 
comrades,  who  have  not  waited  for  her.  In  civilized  hfe  the  best-con- 
ditioned, best-developed  women  bear  children  without  great  discomfort, 
though  there  are  few  who  are  entirely  insensitive  to  the  pain  which  ac- 
companies childbirth,  especially  when  they  experience  it  for  the  first 
time.  Others  who  are  weak  and  badly  formed  find  the  pangs  of  labor 
almost  insupportable,  and  there  are  many  whom  death  would  claim  as 
its  victims,  on  account  of  absolute  inability  to  bring  forth  their  children, 
if  art  did  not  intervene  and  remedy  nature's  deficiencies.  The  obstetric 
art  is  essentially  life-conserving ;  it  is  more  than  that — it  is  life-giving ; 
and  it  was  never  practiced  with  such  skill  and  success  and  discrimina- 
tion in  any  previous  age  of  the  world,  by  the  profession  at  large,  as  are 
exercised  now. 

To  conduct  a  labor  to  a  successful  issue  the  physician  must  determine 
with  reasonable  accuracy  the  following  facts :  that  the  vitality  of  the 
mother  is  not  being  seriously  encroached  upon  by  the  pain  which  she  is 
suffering ;  that  the  birth  canal  of  the  mother  is  of  ample  dimensions  to 
permit  the  extrusion  of  the  child  at  the  proper  time ;  or,  if  the  foregoing 
conditions  are  not  satisfied,  that  the  proper  instrumentalities  are  at  hand 
to  reinforce  the  vitality  of  the  mother,  and  to  furnish  a  safe  delivery, 
and,  if  possible,  the  safe  delivery  of  the  child  as  well.  A  physician  is 
negligent  who  trusts  to  the  unaided  efforts  of  nature  to  efi'ect  delivery 
when  it  is  evident  to  one  of  ordinary  percei^tion  and  experience  that  na- 
ture unaided  cannot  deliver,  or  can  do  so  only  at  the  gravest  risk  to  the 
mother's  tissues  or  life :  the  interests  of  the  child,  though  important,  are 
secondary,  for  many  reasons,  to  those  of  the  mother.  A  physician  is 
negligent,  when  oi)erative  measures  are  required,  who  does  not  call  to 
his  aid  skill  superior  to  his  own  for  the  performance  of  such  operative 
measures,  if  his  own  skill  and  experience  are  insufficient,  if  such  superior 
skill  is  available.  Except  under  extraordinary  conditions,  a  woman 
should  not  be  allowed  to  die  undehvered.  Except  under  extraordinary 
circumstances,  the  life  of  a  child  should  not  be  deliberately  sacrificed  by 
operative  measures.  A  jjliysician  should,  in  the  great  majority  of  cases, 
be  able  to  discriminate  whether  the  interests  of  mother  and  cliild  are 
best  sulisei'ved  by  the  operation  of  version  or  by  the  use  of  the  ol:)stetric 
forceps.  A  physician  should  be  able  to  discriminate,  with  the  assistance 
of  counsel  if  necessary  and  available,  whether  the  interests  of  motlier 
and  child  may  not  be  best  subserved  by  the  performance  of  symphyseot- 
omy or  Caesarean  section.  In  view  of  all  the  resour-ces  which  modern 
obstetrics  places  at  the  command  of  the  pliysician,  including  the  pra(;tice 
of  rigid  asepsis,  wliich  is  only  anotlier  term  for  cleanliness,  there  are  few 
complications  which  place  any  case  of  midwifery  beyond  the  reacli  of 
efficient  relief. 

After  labor  is  concluded  the  puerperal  state  begins.  It  usually  contin- 
ues four  to  six  weeks,  and  is  a  period  of  very  great  importance,  for  it  is 


BIRTH,  SKX,   PREGXASCY,  AXD   DELIVERY.  457 

the  period  in  which  the  uterus  under«]roes  iuvohitiou  by  means  of  contrac- 
tion and  fatty  dejjreneration  of  its  muscular  libers,  the  placental  site  be- 
coming obliterated,  and  by  -vvliich  restitution  to  the  cc)ndition  which  it 
sustained  prior  to  pregnancy  is  established.  This  condition  is,  however, 
never  precisely  identical  with  the  contlition  of  a  uterus  which  has  never 
been  unpregnated,  the  contour  of  the  organ  being  somewhat  more 
rotund,  while  its  external  orifice  almost  invariably  declares  to  the  prac- 
ticed eye  or  finger  that  the  \-irgin  state  no  longer  exists.  While  the 
process  in  question  is  going  on,  especially  in  its  early  stages,  the  condi- 
tion of  the  woman  is  a  very  sensitive  one.  Within  the  uterus,  and  some- 
times in  other  portions  of  the  birth  canal  if  the  labor  has  been  a  severe 
one,  there  is  an  extensive  raw  surface  through  which  poisonous  germs 
may  be  absorl)ed  with  great  facility.  It  is  the  period  in  which  the 
di'caded  and  dreadful  inierjieral  fever,  which  sometimes  sweeps  through 
communities  like  a  pestilence,  is  a  possible  contingency.  Only  since  the 
self-den^nng  labors  and  sacrifices  of  the  lamented  Semmelweiss  has  it 
been  appreciated  that  this  disease  is  preventable  if  the  labor  has  been 
properly  conducted  and  strict  cleanliness  observed  in  all  the  siuTound- 
ings  of  the  patient.  This  disease  is  practically  unknown  among  savages 
and  others  who  lead  an  out-of-door  life.  This  is  not,  however,  on  ac- 
count of  superior  cleanliness  or  caution  on  theii"  part,  but  because  of  the 
beneficial  effects  of  an  out-of-door  life.  In  many  matemits'  hospitals  in 
which  puerperal  fever  once  raged  with  terribly  destructive  effects  it  is 
now  almost  unknown.  It  is  proper  to  reiterate  the  statement  that  a 
physician  is  negligent  who  does  not  observe  the  most  scrupulous  cleanli- 
ness in  all  his  dealings  with  puerperal  women. 

In  ahnost  all  labors,  especially  the  fii"st  which  women  experience,  the 
strain  upon  the  tissues  as  the  child  leaves  the  birth  canal  is  such  that 
more  or  less  tearing  of  them  occiu's.  Such  injuries  are  ordinarily  most 
marked  at  its  outlet,  and  careful  inspection  will  usually  revejil  then*  loca- 
tion and  extent.  Their  importauce  cannot  be  exaggerated  if  we  remem- 
ber that  they  often  furnish  the  opportunity  f«.>r  septic  infection;  hence 
the  necessity  of  treating  them  by  means  of  suitable  hgature  mateiial  as 
soon  as  possible  after  they  have  oeciu-red,  thus  anticipating  any  fm-ther 
injmy  from  such  a  soui'ce.  The  tissues  in  question  may  be  torn  in  any 
direction,  the  mucous  membrane  of  the  vagina  being  torn  longitudiually, 
transversely,  or  obliquely,  or  the  mucous  membrane  of  the  vulva  may  be 
involved,  or  the  injury  may  extend  outward  to  the  skin,  or  through  skin, 
mucoiis  membrane,  fascia,  and  muscle,  finally  going  thi'ough  the  rectum, 
or  it  nuiy  extend  upward  and  invade  the  bladder.  The  injmy  may 
result  in  the  detachment  of  the  fascia  by  which  the  vagina  is  supported, 
without  any  apparent  involvement  at  the  surface.  The  uterus  may  be 
wounded  to  any  extent,  from  a  simple  fissure  at  its  external  orifice  to 
complete  ruptm-e  of  the  organ  and  delivery  of  the  child  into  the  abdom- 
inal cavity.  It  must  therefore  be  plain  that  the  accoucheur  s  duty  has 
not  ended  when  the  fetus  and  its  attachments  have  passed  out  of  the 
mother  s  body  and  into  the  world.  He  should  acquaint  himself  at  the 
earliest  possible  moment  after  the  conclusion  of  labor  with  the  condition 
of  the  maternal  tissues  which  have  been  subjected  to  such  a  severe  strain. 
If  this  were  always  done  as  a  nuitter  of  routine,  much  trouble  would  lie 
ob\'iated  for  patient  and  physician,  and  there  would  be  fewer  invalids 
fi'om  such  a  cause.     In  addition  to  the  e^•idences  of  recent  deliverv  from 


458  -4   SYSTJiM  OF  LEGAL  MEDICINE. 

the  injuries,  wliicli  liave  been  alluded  to,  one  may  also  observe  swelling- 
and  discoloration  of  the  vagina  and  vulva,  enlargement  of  the  veins  of 
the  vulva  and  anus,  and  more  or  less  prolapsus  of  one  or  both  lips  of  the 
cervix  uteri.  In  many  cases  there  will  also  be  paralysis  of  the  bladder 
and  consequent  inability  to  pass  the  mine,  which  may  continue  several 
days  after  delivery. 

As  soon  as  the  contents  of  the  uterus  have  been  expelled  there  is  im- 
mediate shrinkage  or  contraction  of  the  organ  if  the  course  of  events  is 
the  natural  one,  and  instead  of  expending  far  above  the  navel  it  does  not 
extend  much  higher  than  the  symphysis  pubis,  its  size  being  quickly  re- 
duced to  that  of  a  small  cocoanut.  Thenceforward  during  the  puerperal 
state  or  puerperium  it  continues  to  contract,  as  we  have  already  remarked, 
until  the  normal  unimpregnated  size  has  been  reached.  In  some  cases 
the  contraction  is  so  excessive  that  a  condition  of  atrophy  is  reached,  the 
•organ  becoming  reduced  to  the  size  of  a  seckel-pear.  This  is  the  condi- 
tion which  is  known  as  superin volution,  and  it  is  usually  followed  by 
irremediable  sterihty  and  the  menopause.  It  is  a  rare  condition,  the 
writer  having  seen  not  more  than  four  or  five  cases.  In  other  cases  the 
contraction  is  imperfect :  the  organ  remains  nearly  as  large  as  a  base-ball 
for  months,  and  is  more  or  less  lioggy  to  the  touch.  With  it  are  associ- 
ated more  or  fewer  uncomfortable  symptoms,  and  unless  another  preg- 
nancy supervenes  or  the  patient  is  placed  under  the  most  judicious  treat- 
ment the  condition  will  prove  a  very  troublesome  one.  This  is  the  con- 
dition which  is  known  as  subinvolution,  and  is  a  very  common  one. 

The  abdomen,  which  has  been  greatly  stretched  during  gestation,  be- 
comes relaxed  and  flabby,  and  the  more  numerous  the  pregnancies,  and. 
the  shorter  the  interval  between  them,  the  less  disposed  the  tissues  to 
regain  the  tone  and  firmness  which  they  had  before  pregnancy  ever  oc- 
curred. The  skin  of  the  abdomen  shows  furrows  and  striae  and  more 
or  less  pigmentation  in  testimony  of  the  pregnancy  which  has  recently 
occurred. 

The  breasts  swell  and  harden,  and  by  the  thu*d  day  after  dehvery 
lactation  is  usually  estabhshed.  The  wonderful  sensitiveness  of  the 
mammary  glands  and  the  intense  sympathy  which  they  share  with  the 
rest  of  the  genital  apparatus,  and  especially  with  the  nervous  system, 
are  seen  in  the  frequency  with  which  they  become  inflamed  after  delivery 
in  response  to  any  disturbance  in  the  parts  A\ith  which  they  are  in  sym- 
pathy. Lochial  and  lacteal  secretions  are  necessary  concomitants  of  the 
puerperal  state  in  normal  cases,  and,  eonversel}',  when  they  ai-e  observed 
the  obvious  inference  must  be  that  the  pregnant  state  has  recently  ex- 
isted. But  it  nmst  not  be  forgotten  that  a  bloody  discharge  from  the 
vagina  and  milk  in  the  breasts  may  occm'  independently  of  pregnancy, 
while  it  is  also  possible  that  both  may  be  absent  though  pregnancy  and 
delivery  have  been  recent.  The  lochial  dischai'ge  is  composed  of  blood 
and  broken-down  tissue,  and  implies  that  the  usual  degenerative  changes 
in  the  uterus  are  progressing.  It  usually  continues  three  or  four  weeks, 
gradually  becoming  less  abundant  and  more  watery  in  character.  It  is 
a  very  important  index  to  the  physician  of  the  situation  within  the  ute- 
j'us,  and  if  it  suddenly  ceases  or  becomes  unusually  abundant  or  very 
offensive  it  is  a  warning  that  the  situation  within  the  uterus  is  not  a 
■desirable  or  proper  one,  and  a  plain  indication  that  interference  is  neces- 
sary.    The  lacteal  secretion  is  susceptible  of  great  variation  as  to  quan- 


liiirni,  si-jx,  rnKdXJXcv,  axd  dklivert.  439 

tity  and  quality,  aud  the  pliy.sieiuii  sliould  Ije  alert  to  discover  the  first 
evidence  of  disturbance  in  this  direction,  for  it  is  then  that  the  trouble 
may  be  averted  or  minimized. 

The  suppositition  or  suljstitution  of  a  cliild  for  fraudulent  purposes  is, 
of  course,  possible,  especially  if  there  has  been  collusion  on  the  part  of  the 
jihysician  or  midwife.  Cases  ai'c  recorded  in  which  such  a  fraud  has 
been  practiced  for  the  purpose  of  securing  an  iuheritance  (see  Wharton 
and  Stille,  vol.  iii.,  sec.  87) ;  but  detection  cannot  be  avoided  if  the  signs 
of  recent  pregnancy  and  delivery  are  wanting  in  the  supposed  mother. 
There  is  no  way  of  counterfeiting  such  signs,  taken  as  a  whole,  which  is 
known  to  the  writer.  The  same  may  be  said  in  regard  to  fe'ujned  ddivery. 
Many  women  have  deceived  themselves  and  their  attendants,  either  will- 
fully or  unconsciously,  during  their  supposed  pregnancy,  and  have  finally 
taken  their  beds  in  expectation  of  delivery.  The  possibility  of  such 
occiuTences  demonstrates  the  necessity  of  diagnosticating  the  condition 
■of  a  woman  by  means  of  a  careful  examination  and  not  by  the  statements 
W'liich  may  Ije  made,  if  one  would  preserve  his  reputation  and  liis  self- 
respect. 

Suppression  of  a  child  after  it  has  been  delivered  is  possible  either 
through  accident  or  by  design  on  the  part  of  the  mother.  Cases  are  suf- 
ficiently numerous  in  which  the  mother  has  been  suddenly  taken  in  labor 
and  has  gone  to  stool  apparently  for  the  purpose  of  emptying  her  bowels : 
the  child  has  been  hovn  and  has  perished  from  exposure,  the  mother 
returning  to  her  household  duties  as  if  nothing  had  happened.  It  is 
possible  to  conceive  that  such  cases  and  others  of  similar  precipitate 
labor  may  occui'  without  criminal  intent  on  the  part  of  the  mother, 
but  the  inference -in  most  cases  will  be  that  criminal  intention  was 
present. 

The  obstetric  art  has  made  a  distinct  advance  in  the  last  decade  in  the 
treatment  of  cases  in  which  labor  v/as  likely,  according  to  former  meth- 
ods of  treatment,  to  prove  serious  or  even  fatal  to  the  mother  or  the 
■child,  or  to  both.  Unfortunately  there  are  man}'  women  who  are  so  de- 
formed as  to  theii'  pelves,  that  it  would  seem  impossible  that  they  could 
be  delivered  of  living  full-term  children  by  the  uatiu-al  process,  it  indeed 
they  could  be  delivered  of  them  at  all.  The  alternatives  are  the  destruc- 
tion of  the  clidd,  with  dismemberment  if  necessary,  and  deliver}-  through 
the  contracted  natui-al  passage,  the  induction  of  labor  at  tlu'  seventh 
month  or  subsequently  in  the  hope  of  obtaining  a  li\dng  child,  or  the 
removal  of  the  cliild  at  maturity  through  an  opening  in  the  motliei''s 
al)domen  and  uterus  (Ca?sarean  section),  or  the  division  of  the  bones  at 
the  symphysis  (symphyseotomy).  If  the  child  is  dead  when  the  obste- 
trician takes  charge  of  a  given  case  it  has  no  rights  which  ai'c  to  be  re- 
garded, and  it  should  be  delivered  in  such  a  manner  as  ^\^)l  offer  the 
highest  degree  of  safety  and  comfort  to  the  mother,  whether  with  instru- 
nu'uts  or  without  them.  But  if  the  child  is  living  it  has  natural  and 
legal  rights  which  nnist  not  be  ignored.  The  Eoman  Catholic  Church 
forbids  the  deliberate  sacrifice  of  the  cliild,  even  though  the  life  of  the 
mother  may,  in  all  prol)ability,  be  saved  thereby.  There  are  certain  con- 
tingencies in  which  the  mandate  of  that  church  would  be  disregarded, 
especially  if  tlie  obstetrician  were  not  of  that  faith.  If  a  child  were 
manifestly  feeble  or  deformed,  or  so  constituted  that  it  could  not  accord- 
ing to  human  judgment,  survive,  the  obstetrician  would  be  derelict  if  lie 


460  ^   SYSTEM  OF  LEGAL  MEDICINE. 

allowed  its  useless  existence  to  jeopardize  the  life  of  its  mother.  But 
mere  disproportion  between  the  mother's  pelvis  and  the  dimensions  of  a 
living  and  presumably  normal  child  would  not,  as  a  rule,  be  a  valid  ex- 
cuse for  depriving-  the  child  of  life.  If  the  mother  is  already  in  a  dying- 
condition  when  the  obstetrician  arrives  ui)on  the  scene,  and  the  child  is 
vigorous  in  its  movements  and  has  a  vigorously  acting  heart,  the  ques- 
tion of  quickly  removing  it  by  Caesarean  section  becomes  pertinent. 
Such  an  operation  has  been  done  with  the  result  of  obtaining  a  living 
child.  Of  coui'se  it  requires  not  a  little  fortitude  to  undertake  such  an 
operation.  The  chances  of  obtaining  a  living  child  are  diminished  if 
Csesarean  section  is  deferred  until  the  mother  has  expired.  Such  opera- 
tions have  also  been  performed :  they  are  usually  unsuccessful,  for  the 
vitality  of  the  child  is  dependent  upon  vitality  in  the  mother. 

The  induction  of  premature  labor  at  the  seventh  month,  when  the 
birth  canal  of  the  mother  is  not  sufficiently  capacious  to  allow  the  pas- 
sage of  a  fully  grown  child,  is  a  procedure  which  is  directed  chiefly  in  the 
mother's  interests.  A  seven  months'  child,  as  we  have  already  stated, 
has  not  the  vitality  or  the  development  of  a  full-term  child,  and  there  is 
not  onl}^  the  risk  that  a  child  thus  prematurely^  delivered  may  not  be  liv- 
ing when  delivered,  but  that  attempts  to  rear  it,  if  living,  may  be  futile. 
The  homes  of  the  poor  and  careless,  where  such  children  most  frequently 
come,  are  illy  equipped  for  the  painstaking  efforts  which  are  required  by 
such  feeble  infants.  The  mother  suffers  less  risk  by  such  a  procedure 
than  by  any  other  which  has  thus  far  been  debased,  and  no  unusual  skill 
is  required  of  the  obstetrician  for  its  performance. 

Of  the  two  remaining  measm-es  suggested  for  the  relief  of  unusual 
hindrances  to  delivery  the  indications  for  their  employment  differ.  Sym- 
physeotomy enlarges  the  dimensions  of  the  pelvis  at  its  brim  or  inlet  in 
all  dii-ections,  but  particularl}"  in  its  transverse  diameter,  through  wliich 
the  longest  diameter  of  the  fetal  head  usually  first  descends.  The  gain 
in  this  dimension  may  be  as  much  as  three  quarters  of  an  inch  or  even 
an  inch.  If  by  such  an  increase  in  area  the  birth  canal  might  bec(3me 
sufficiently  spacious  for  the  passage  of  the  child,  S3anphyseotomy  should 
be  the  operation  of  choice  or  election.  The  operation  consists  in  divid- 
ing the  tissues  which  cover  the  joint  formed  by  the  union  of  the  two 
pubic  bones,  and  then  dividing  the  structui-es  which  hold  the  bones  to- 
gether. The  |)ressure  of  the  child  upon  the  structures  of  the  pelvis  being 
constant,  as  soon  as  the  bones  are  di\dded  the  pehis  expands  like  a  hoop 
which  has  been  cut  and  the  ends  pulled  apart.  This  may  give  the  addi- 
tional half  inch  or  inch  of  space  which  will  be  necessary  for  the  delivery 
of  tlie  child.  Even  when  this  has  been  done  delivery  is  not  always  accom- 
plished Tjy  the  unaided  efforts  of  nature,  but  a  way  has  been  opened  so  that 
if  further  use  of  instruments  becomes  necessary  they  can  be  employed  with 
gi'eater  advantage  than  before  the  operation.  If  the  utmost  space  that 
could  be  gained  by  such  a  procedure  still  leaves  the  conditions  unfavor- 
abfe  for  delivery  the  alternative  must  be  Cassarean  section,  which  signi- 
fies an  iniision  in  the  abdomen  of  the  mother,  another  in  her  uterus,  and 
removal  of  the  child  through  the  two  openings  thus  made.  The  experi- 
ences of  the  past  ten  years  have  made  this  (qjeration  relatively  safe  in- 
stead of  almost  iTiiiformly  fatal  as  was  formerly  the  case.  It  is  the  last 
resort,  with  its  modificMtions,  of  obstetric  surgery,  and  if  performed  upon 
a  woman  who  has  not  been  exhausted  by  ineffectual  attempts  at  deliver}^ 


BIRTH,  SEX,   niEGXAXCY,  AM)   DELIVERY.  4G1 

by  other  modes — that  is,  if  made  a  matter  of  choice  and  performed  at  the 
most  auspicious  moment,  which  is  usually  considered  to  be  the  moment 
when  labor  has  commenced — the  chances  for  success  for  both  mother  and 
child  are,  as  a  rule,  very  good.  A  certain  amount  of  skill  is  rc(juired  in 
the  performance  of  either  symphyseotomy  or  Ca^sareau  section,  and  this 
fact  seems  to  be  overlooked  by  many  writers.  It  does  not  folhjw  that 
one  who  is  clever  in  the  use  of  the  obstetric  forceps  or  in  the  perform- 
ance of  manual  version  would  be  equally  successful  in  performing  s\'m- 
physeotomy  or  Ca'sarean  section ;  hence  such  operations  will  always  ap- 
pertain to  the  specialist  rather  than  to  the  general  practitioner.  A  more 
exact  definition  of  the  scope  of  these  operations  is  not  appropriate  to  a 
work  of  this  character.  Their  history  has  been  very  gratifying,  since  it 
includes  the  restoration  to  health  and  usefulness  of  many  mothers  and 
the  rescue  from  certain  death  of  mau}^  children.  Not  a  few  instances 
are  on  record  in  which  Ca^sareau  section  has  been  repeatedly  performed 
upon  the  same  woman,  the  boon  of  living  childi-en  being  thus  accorded 
to  many  who  could  have  them  in  no  other  wa}'. 

The  number  of  children  which  a  woman  may  have  or  should  have  is 
a  question  which  cannot  be  answered  in  a  general  way.  Conditions  of 
law,  physiology,  and  casuistry  may  all  be  involved  in  its  consideration 
and  may  all  conflict  with  one  another.  It  is  not  generally  appi-eeiated 
that  an  enormous  number  of  the  cases  in  which  pregnancy  occurs  are 
abortive.  Tliis  fact  has  its  favorable  and  its  unf avoidable  aspects.  If  all 
pregnancies  resulted  in  the  birth  of  living  children  it  would  be  almost 
inevitable  that  overpopulation  would  quickly  stare  many  communities  in 
the  face.*  On  the  other  hand,  multitudes  of  fetuses  are  like  blighted 
fruit,  not  having  sufficient  vitality  to  mature ;  other  multitudes  are  killed, 
murdered  in  nfero,  and  in  the  vast  majority  of  cases  neither  those  who 
commit  the  crimes  nor  tlieii*  accomplices  are  ever  brought  before  courts 
of  justice,  the  rights  of  the  murdered  children  being  absolutely  ignored. 
It  was  contended  in  ancient  medical  tradition  that  the  pregnant  state 
was  the  normal  one  for  women,  and  certainly  the  anatomy  of  the  endo- 
metrium, with  its  de^*elopment  and  degeneration  during  each  menstrual 
cycle,  would  seem  to  sustain  such  a  supposition.  But  it  must  never  be 
forgotten  that  a  pregnant  woman  has  two  existences  to  provide  for — her 
own  and  that  of  the  fetus  which  she  is  carrying ;  and  if  her  stock  of 
vitality  is  insufficient  to  properly  sustain  herself,  it  is  manifestly  unjust 
to  her  to  impose  upon  her  the  burden  of  sustaining  herself  and  another : 
it  is  also  unfair,  or  at  least  unfortunate,  to  her  offspring  that  it  should 
come  into  the  world  handicapped  with  an  inheritance  of  physical  debility. 
This  is  no  plea  for  criminal  aliortion,  but  a  protest  against  ill-assorted 
marriages,  unrestrained  sexual  indulgence,  and  failiu'e  to  guard  against 

*  This  statement  is  made  with  due  cautiou  and  resevvation  because  of  the  per- 
fectly oljvious  fact  that  in  many  parts  of  the  Avovkl  conditions  of  climate,  race,  etc., 
are  nnfavorahle  to  fecundity,  even  though  abortion  never  occurred.  Dr.  F.  A.  Cook, 
ethnologist  to  the  tirst  Peary  North-Greenland  expedition,  states  that  among  the 
Esquimaux,  Avith  whom  the  impulses  of  nature  are  followed  without  restraint,  abortion 
seldom  occurs  (though  some  of  the  women  are  sterile,  and  death  during  labor  is  :in 
occasional  occurrence).  Dm-ing  the  fifty  years  or  more  that  these  peojile  have  been 
under  ol>serva,tion,  though  living  under  natural  conditions  and  in  surroundings  to 
which  they  have  become  habituated,  they  have  increased  in  numbers  very  slowly. 
It  must  be  added  that  overpopulation  is  effectually  prevented  by  their  custom  of  kill- 
ing the  helplessly  aged,  and  infants  whose  mothers  have  died. 


462  ^  SYSTEM   OF  LEGAL  MEDICLXE. 

impregnation  wlien  enfeebled  and  diseased  offspring  must  be  an  inevi- 
table consequence. 

After  impregnation  has  taken  place  the  attitude  'wliicli  tlie  physician 
should  take  toward  the  mother  and  her  unborn  offspring  should  be  a 
•conservative  one.  He  cannot  tamper  with  life.  Those  cases  only  are 
excepted  in  which  f ailui'e  to  terminate  the  pregnancy  prematui*ely  would 
almost  certainly  result  speedily  in  the  death  of  the  mother,  and,  of  course, 
of  the  child  also. 

In  the  case  of  women  who  are  suffering  with  serious  constitutional 
disease,  including  pulmonary  phthisis,  ckronic  neplmtis,  syphihs,  and 
■diabetes  mellitus,  it  is  believed  that  pregnane}^  should  be  prevented  if 
possible.  It  is  hard  thus  to  decide  for  those  with  whom  the  maternal 
instinct  is  strong,  but  it  is  better  to  suppress  natural  tendencies  or  self- 
love  than-  to  work  lasting  injustice  to  others.  If  a  woman  is  not  debili- 
tated by  disease  and  is  of  suitable  physique  for  the  requirements  of 
pregnancy,  parturition,  and  lactation,  she  will  usually  be  benefited  rather 
than  harmed  by  impregnation  occiu-ring  as  frequent^  as  it  may  occur 
naturalty  in  the  ordinary  course  of  temperate  married  life.  It  will  be 
understood  that  these  statements  refer  only  to  the  ph3'sical  side  of 
woman's  life ;  their  bearing  in  other  directions  is  not  under  consideration. 

Among  our  native  American  population,  especiall}'  among  those  who 
are  provident  and  temperate,  the  number  of  children  which  a  woman 
"bears  rarely  exceeds  six ;  usually  it  is  under  rather  than  over  this  number. 
Who  can  say  that  it  is  not  better  to  raise  and  train  carefully  a  small 
number  of  children,  both  with  regard  to  the  interests  of  the  individuals 
themselves  and  those  of  the  state,  than  to  breed  immoderately,  with  re- 
sulting deterioration  of  the  offspring  and  defective  bringing  up  ? 

Six  pregnancies  at  intervals  of  two  or  three  years  will  consume  as 
much  ^itality  as  the  average  American  woman  can  spare  for  such  pur- 
poses and  at  the  same  time  do  justice  to  the  other  duties  of  life.  How- 
ever natural  it  may  be  for  a  healthy  woman  to  bear  children — and  that 
is  conceded — it  certainly  is  not  the  first  and  only  duty  winch  she  has  to 
consider. 

There  are  many  indications  or  signs  which  declare  to  the  eye  of  an 
observant  physician  that  pregnancy  is  present  or  has  been  present  in  a 
given  case.  In  the  absence  of  these  signs  it  is  not  well  to  affirm  too 
positively  that  it  has  not  been  present.  A  woman's  statements  that  preg- 
nancy has  or  has  not  existed  at  a  previous  time  are  useful  only  as  they 
are  eonfii-matory  of  a  diagnosis  which  must  be  based  essentially  on  the 
sight  and  touch  of  the  phj^sician.  The  facial  expression  of  a  woman 
who  has  borne  children  is  entu-ely  different  from  that  of  one  who  has 
not.  It  is  frequently  alluded  to  as  the  matronly  or  the  maternal  expres- 
sion, and  is  easily  caught  if  one  compares  the  photograph  of  a  girl  who 
is  just  married  with  one  of  the  same  person  with  her  baby  in  her  arms 
a  year  or 'two  later.  Its  description  is  almost  impossible  in  words :  some- 
times it  seems  to  consist  in  a  broadening  of  the  face,  an  enlargement  of 
the  features ;  sometimes  there  is  a  benignancy  of  expression  which  is 
entirely  sni  generis — the  radiancy  of  maternity  which  the  old  Italian  mas- 
ters incorporated  in  some  of  their  madonnas. 

The  breasts  of  one  who  has  borne  children  are  usually  well  developed, 
especially  if  the  childi'en  have  been  nursed.  Functional  activity  tends  to 
the  enlargement  of  these  glands  as  it  does  to  that  of  any  others  \  but  if  the 


BIRTH,  SEX,  PREGNANCY,  AND  DELIVERY.  463 

quantity  of  fat  associated  witli  tlie  glands  is  small  the  breasts  may  not 
be  conspicuously  large,  though  serving  sufficiently  well  the  object  of  lac- 
tation. The  pa!pilla3  of  the  areoke  of  the  breasts,  also  the  nipjjles,  are 
suggestive  by  their  prominence  and  enlargement  that  pregnancy  has  ex- 
isted ;  but  the  evidence  derived  from  the  breasts  may  be  misleading,  and 
it  is  chietiy  of  value  when  combined  with  other  evidence.  The  scars,  the 
folds,  and  the  pigmentation  of  the  skin  upon  the  abdomen  are  also  sug- 
gestive. They  are  sometimes  lacking  in  distinctness,  especially  if  a  woman 
has  borne  but  one  child,  or  if  the  nutrition  of  her  body  is  unusually 
good ;  but  they  teR  an  almost  unmistakable  stoiy  in  women  who  have 
been  pregnant  several  times,  repeated  stretching  having  destroyed  the 
natural  apx)earance  of  the  skin  and  the  ordinary  contractile  force  of  all' 
the  tissues  of  the  anterior  abdominal  wall.  With  regard  to  the  e^ddence 
furnished  by  the  appearance  of  the  external  genitals  there  may  be  little 
that  is  suggestive  if  pregnancy  never  proceeded  to  term,  but  if  it  had  so 
proceeded  the  stretching  and  tearing  associated  T\-ith  the  delivery  of  the 
child  would  almost  certainly  leave  behind  some  e"vidence  as  to  the  fact. 
If,  however,  the  wounds  which  were  made  have  been  skillfully  closed, 
determination  as  to  the  pre\dous  existence  of  pregnane}^  may  be  almost 
impossible.  The  vaginal  mucous  membrane  of  one  who  has  borne  chil- 
dren is  smoother,  less  rugose  than  it  is  in  the  virgin,  the  folds  having 
been  stretched  or  spread  out.  The  vaginal  portion  of  the  cer^dx  in  the 
parous  woman  presents  decided  points  of  dissimilarity  from  the  condi- 
tions in  the  vii-giu :  it  is  larger,  its  extremity  suggests  the  section  of  a 
cylinder  instead  of  a  cone  (as  in  the  virgin),  and  its  os  or  external  open- 
ing is  a  transverse  slit  of  variable  extent  instead  of  a  round  opening. 
The  last-mentioned  fact  has  heretofore  been  considered  a  diagnostic  point 
of  unfading  accuracy  ia  differentiating  those  who  have  been  pregnant 
from  those  who  have  not.  Since  the  operation  of  trachelorraphy  has 
come  into  vogue,  however,  it  has  frequently  been  found  difficult  to  de- 
cide from  this  sign  alone  in  regard  to  the  question  of  a  pre^dous  impreg- 
nation. From  the  foregoing  statements  it  will  be  e\ddent  that  the  cases 
^\tII  be  rare  and  infrequent  in  which  it  will  not  be  possible  for  a  physi- 
cian of  experience,  especially  if  he  has  devoted  considerable  attention  to 
the  practice  of  obstetrics  and  gynecology,  to  state  mth  considerable  pre- 
cision whether  pregnancy  has  ever  existed  in  a  given  case.  If  operations 
have  been  performed  upon  the  pelvic  organs  the  inferences  therefi'om 
will  sometimes  be  of  value  and  sometimes  they  will  not.  The  scar  of  an 
incision  upon  the  abdomen  may  be  an  indication  that  Ctpsarean  section 
has  been  performed,  Init  it  may  also  indicate  that  an  operation  for  dis- 
ease of  the  ovaries  lias  been  performed,  and  if  those  organs  were  removed 
subsequent  pregnancy  would  be  impossilile.  The  scar  might  also  indi- 
cate that  an  operation  had  been  performed  for  appendicitis  or  any  other 
disease  of  the  abdominal  viscera  entirely  distinct  from  disease  of  the 
genital  organs.  Scai-s  upon  the  vagina  or  uterus  might  also  signify*  the 
performance  of  operations  which  had  no  relation  to  pregnancy.  Testi- 
mony of  this  character  is  therefore  necessarily  inconclusive  and  indirect, 
and  should  not  be  accepted  by  a  com*t  of  justice  as  evidence  per  se  that 
pregnancy  has  existed. 

Oljstetrics  or  midwifery  is  indeed  a  well-nigh  perfect  art.  A  correct 
appreciation  of  its  principles  is  more  generally  diffused  than  ever  before, 
and  there  is  scarcely  a  complication  which  can  arise  which  is  not  suscep- 


4G4  ^   SYSTEM  OF  LEGAZ  MEDICINE. 

tible  of  successful  treatment  by  those  wlio  are  masters  of  the  art.  The 
number  of  those  who  have  acquii-ed  this  mastery  is  increasing  year  by 
year.  The  obstetrician  who  practices  in  the  cities  is  esj^eciall}^  conscious 
of  these  facts,  because  to  the  city  hospitals  the  greater  number  of  those 
who  suffer  from  the  accidents  of  parturition  are  brought  for  reparative 
treatment.  The  number  of  those  who  suffer  from  certain  forms  of  these 
accidents  is  far  less  than  it  was  a  few  years  ago.  Take,  for  example,  the 
accident  of  vesicovaginal  fistula,  one  of  the  most  distressing  in  the  entu'e 
category'  of  parturition  injuries,  resulting  fi'om  a  severe  or  a  badl}'  man- 
aged labor.  A  few  years  ago  our  special  hospitals  were  tilled  with  such 
suffei'ers :  now  thej^  are  rarely  seen.  This  must  prove  that  midwifery 
and  its  sister-art,  siu-gical  gynecology,  are  more  inteUigently  and  more 
successfully  practiced  than  fonnerly.  The  question  then  arises.  Why  is 
it  that  so  many  women  still  continue  to  i3resent  themselves  for  relief  from 
the  accidents  of  labor  °?  To  this  question  several  answers  are  possible. 
Fu'st,  there  are  certain  cases  in  which,  owing  to  serious  faults  and  defects 
of  structui'e,  injury'  cannot  be  prevented,  no  matter  how  skillful  or  in- 
telhgent  the  obstetrician  may  be.  Again,  the  labor  may  have  been  proj)- 
erly  conducted  and  terminated,  but  siibsequent  carelessness  or  injudicious 
conduct  on  the  part  of  the  j^atient  may  have  led  to  conditions  which  could 
only  be  reheved  by  surgical  measures ;  or  an  unskillful  midwife  or  even 
an  unskillful  or  badly  equipped  obstetrician  may  have  been  responsible 
for  the  injury ;  or,  finally,  bad  results  may  have  come  about  through  no 
aj^jjarent  en-or  on  the  part  of  the  ]^h5^sician  or  the  patient,  for  reasons 
which  cannot  be  explained.  Unavoidable  accidents  from  first  labors  are 
stm  quite  fi*equent  and  probabty  always  will  be  when  the  tissues  have  a 
tendency  to  tear  rather  than  to  stretch,  as  is  so  frequently  the  case  when 
women  do  not  become  i^regnanfuntiL  after  they  have  passed  their  thirtieth 
year.  The  particular  forms  which  these  injui-ies  may  take  have  akead}^ 
been  noted.  It  is  well  to  reiterate  the  necessity  that  the  obstetrician 
caref idly  examine  his  patient  after  labor  has  been  concluded  and  at  once 
repair  the  damage  as  accurately  and  comj)letely  as  possible.  There  are 
cases  in  which  the  excuse  for  not  following  so  %dgorous  and  thorough  a 
line  of  ti-eatmeut  seems  entu-ely  valid :  the  labor  may  have  occurred  at 
night,  and  in  the  imperfect  light  which  was  available  an  injury  may  have 
been  overlooked ;  or  the  cramped  and  contracted  hmits  and  apphances  of 
a  tenement-house  may  have  fm-nished  obstacles  wliich  at  the  moment 
seemed  insuperal^le ;  or  the  patient  may  have  been  so  exhausted  by  her 
.sufferings  that  additional  exposure  and  pain  even  for  a  few  minutes 
would  have  seemed  unwarrantable.  But  whatever  the  excuse,  whether 
valid  or  uivalid,  it  often  happens  that  neglect  to  take  the  precautions 
mentioned  results  in  infection  thi'ough  the  wounded  tissues,  with  subse- 
quent scaiTing  and  contraction,  or  in  inflammatory  disease  of  the  uterus, 
with  subsequent  involvement  of  the  o^dducts  and  ovaries. 

If  the  ipatient  leaves  her  bed  too  soon,  or  is  exposed  to  cold,  or  is  not 
kept  suificieutty  clean,  e^dl  results  may  foUow  for  wliich  the  ph^'sician  is 
in  no  way  responsible,  for  he  would  not  have  aUowed  the  imprudence  or 
the  exposm-e  if  he  could  have  prevented  it.  The  mother  of  a  family 
among  the  poor  is  often  compelled  b}^  stern  necessity  to  take  risks  after 
her  labor  which  a  woman  in  more  comfortable  circumstances  would 
never  be  subjected  to.  She  is  obliged  to  leave  her  bed  and  attend  to  her 
household  duties  long  before  she  is  in  any  condition  to  do  so,  and  the 


BTJlTn,  SEX,  niEGNANCY,  AND   DELIVERY.  4(;r, 

penalty  in  many  cases  is  a  very  severe  one.  Finally,  no  nnitter  how  skill- 
ful or  intelligent  the  physician  or  the  midwife  may  be,  no  matter  how 
careful  or  how  clean  in  their  treatment,  there  is  a  certain  iniml)er  of 
cases  which  go  wrong  from  the  beginning,  not  only  among-  the  ig-norant, 
the  poor,  and  the  careless,  but  among  the  well-to-do  and  the  careful. 

In  addition  to  the  mischievous  results  of  severe  lal)or  upon  the  structure 
of  the  genital  and  urinary  organs,  there  are  other  morljid  conditions  affect- 
ing women  who  have  been  pregnant,  which  are  sometimes  secondary  to 
and  dependent  upon  those  injuiies  which  they  have  received,  and  some- 
tinuis  occur  independently  of  or  in  the  absence  of  such  injuries.  Malig- 
nant disease  of  any  part  of  the  body,  which  may  liave  been  quiescent 
during  pregnancy  (though  it  frequently  progresses  jjari  pofisn  with  the 
pregnancy),  may  assume  a  dangerous  aspect  and  progress  i-apidly  to  a 
fatal  issue  as  soon  as  pregnancy  has  terminated.  The  same  is  true  of 
tubercular  disease  of  the  different  parts  of  the  bod}',  also  of  the  chronic 
inflammatory  diseases  of  the  kidne3's,  etc.  One  of  the  inost  imi:)ortant 
grou})s  of  the  morljid  sequels  of  parturition  includes  the  mental  disorders, 
and  these  may  occur  with  or  without  the  surgical  injuries  before  men- 
tioned. The  mental  derangement  may  take  the  violent  form  of  mania 
in  its  varying  grades,  or  the  subdued  form  of  melancholia,  also  of  vary- 
ing degree.  In  a  general  way  it  may  be  said  to  be  induced  by  the  in- 
tense agony  of  parturition,  manifesting  itself  in  a  burst  of  frenzy,  tran- 
sient, disappearing  with  the  conditions  which  excited  it ;  by  preexisting 
tendency  to  mental  disease,  which  matures  either  into  occasional  attacks 
of  mania  or  into  a  prolonged  period  of  melancholia  within  a  few  daj^s  or 
weeks  after  pregnancy  is  over ;  or  by  septic  influences  or  material  operat- 
ing during  the  period  of  pregnancy  through  the  medium  of  the  blood 
and  lymph  currents,  or  after  labor  has  terminated. 

The  subject  of  legal  procedures  against  physicians  in  cases  in  which 
parturition  has  resulted  unfavorably  in  one  way  or  another  is  an  interest- 
ing and  most  important  one.  Such  procedures  are  usually  most  annoy- 
ing and  vexatious,  involving  much  time  and  expense,  and,  it  may  be,  the 
very  possiljility  to  the  physician  of  living  and  working  at  his  calling  in 
the  community  where  all  his  interests  are  located.  Such  interests  nuiy 
have  been  built  up  by  the  laborious  work  of  numy  years,  and  it  not  in- 
frequently happens  that  they  are  jeopardized  by  those  who  should  be 
attached  to  the  x>bysician  by  all  the  claiiiis  of  gratitude  and  hunuinity. 
Let  us  see  for  a  moment  what  are  the  phases  of  obstetrical  practice.  In 
the  majority  of  cases  it  consists  mainly  in  cleanliness  on  the  part  of  all 
who  are  in  an}'-  way  concerned,  in  not  being  meddlesome,  and  in  "  giving 
nature  a  chance."  Such  cases  may  be  handled  by  intelligent  mid^nves 
with  perfect  propriety.  Other  cases  demand  the  exercise  of  good  judg- 
ment, common  sense,  and  a  reasonable  degree  of  mechanical  skill ;  they 
are  bej^ond  the  sphere  of  the  midwife,  and  should  be  attended  by  physi- 
cians of  at  least  the  average  intelligence.  The  remaining  minority  of 
cases  require  the  highest  qualities  of  judgment  and  the  highest  degree  of 
intelligence  and  mechanical  skill — qualities  which  are  possessed  by  but 
very  few.  The  average  ph^^sician,  who  has  had  no  opportunity  or  train- 
ing in  special  lines  of  work,  should  not  be  held  accountable  for  injmies 
resulting  from  supreme  difficulties,  nor  for  injuries  which  have  resulted 
from  the  carelessness  or  imprudence  of  the  patient,  nor  for  those  which 
liave  resulted  from  her  failure  or  unwillingness  to  comply  with  conditions 


466  ^  SYSTEM  OF  LEGAL  MEDICINE. 

wliicli  Lie  or  one  of  greater  experience  and  skill  has  deemed  essential  to 
her  welfare. 

The  law,  which  recognizes  the  physician's  work  as  largely  one  of  hu- 
mane effort,  which  exempts  him  from  jury  duty  and  other  duties  whick 
are  incumbent  upon  the  ordinary  citizen,  should  shield  him  also  from 
the  attacks  of  mischievous  and  irresponsible  persons  in  the  matter  of  the 
discharge  of  his  duty  in  behalf  of  partuiieut  women.  In  consideration  of 
the  present  status  of  the  science  and  art  of  obstetrics,  and  of  the  oppor- 
tunities which  are  now  widely  diffused  for  obtaining  the  necessary  infor- 
mation and  experience  in  this  direction,  it  may  be  boldly  said  that  no  one- 
who  practices  in  tliis  department  should  offer  the  plea  of  inabilitj^  to  per- 
form the  operations  which  are  necessitated  by  the  lesser  accidents  whick 
are  incidental  thereto.  Certainly  one  who  is  incompetent  to  do  suck 
operations  is  not  a  proper  person  to  practice  obstetrics,  for  we  have  seen, 
how  important  is  their  bearing  upon  the  future  weKare  of  the  individual.. 
Besides,  in  isolated  communities  and  sometimes  even  in  the  cities,  the 
services  of  the  skilled  specialist  are  often  quite  unavailable,  and  unless, 
tke  operations  in  question  are  performed  at  tke  time  tke  injuries  are  re- 
ceived they  are  either  not  done  at  all,  to  the  possible  detriment  of  the  indi- 
vidual, or  they  entail  no  little  expense  and  annoyance  by  being  done  at  a 
subsequent  period,  perhaps  necessitating  a  prolonged  absence  from  home. 

In  the  presence  of  the  serious  complications  of  midwifery — for  ex- 
ample, such  as  require  the  opening  of  the  abdomen,  and  incision,  repair^ 
or  removal  of  the  uterus  or  other  important  structure — what  is  the  duty 
of  the  average  obstetrician  with  but  little  surgical  experience  or  skill  and 
no  experience  at  all  in  suck  supreme  emergencies  ?  Tke  supposition  is, 
furtkermore,  tkat  ke  is  unable  to  call  to  kis  aid  tke  skilled  assistance 
necessary  for  suck  an  occasion.  The  condition  is  a  dilemma  either  horn 
of  which  is  disagreeable  enough  to  take.  Either  he  must  attempt  a  seri- 
ous, delicate,  and  difficult  operation  for  which  he  has  neither  experience 
nor  fitness,  with  a  bare  chance  of  success  if  it  is  done  properly,  and  the' 
certainty  that  it  will  make  matters  worse  if  not  done  proper!}^,  or  ke  must 
fold  kis  kands  and  do  uotking  except  enforce  cleanliness  and  drainage^ 
witk  tke  possibility  tkat  nature  may  furnisk  tke  one  ckance  in  tke  pa- 
tient's favor  wkick  is  necessary  to  overcome  tke  situation.  Tke  lesser 
evil  would  seem  to  tke  wi^iter  to  be  involved  in  tke  expectant  or  do-notk- 
ing  plan,  and  ke  would  tkerefore  counsel  against  tke  performance  of  tke 
operations  in  question  by  tke  inexperienced.  Tkere  is  no  ckance  of  suc- 
cess in  ignorant  and  kapkazard  rusking  into  suck  serious  situations  for 
tke  sake  of  doing  sometking,  tke  most  tkat  can  be  aceomplisked  being  to 
bring  tke  operative  measures  into  discredit.  It  is  better  to  do  notking 
tkan  to  do  sometking  raskly  and  unwisely.  It  is  better  to  kave  tke  con- 
sciousness tkat  a  patient  died  because  one  did  not  know  kow  to  relieve 
ker  tkan  to  feel  certain  tkat  ske  died  because  of  tke  injudicious  violence 
wkick  was  inflicted  upon  ker.  Tke  performance  of  tkese  major  obstetri- 
cal operations  must  ever  be  limited  to  tke  comparatively  few,  and  tke 
part  of  prudence  and  wisdom  will  consist  ratker  in  anticipating  and  pro- 
viding for  tkese  evils  tkan  in  abortive  attempts  to  remedy  tkem  witk 
means  wkick  are  almost  certain  to  prove  ineffectual  and  disastrous. 


ABORTION  AND  INFANTICIDE. 

BY 

CHARLES  JEWETT,  A.M.,  M.D.,  Sc.D.. 


ABORTION. 

By  the  term  abortion,  or  miscarriage,  as  used  iu  criminal  law,  is  under- 
stood the  unlawful  termination  of  pregnancy  at  any  period  of  gestation. 
The  distinction  observed  in  medicine  between  the  terms  abortion  and  pre- 
mature labor  is  not  recognized  iu  law.  An  abortion  is  said  to  be  com- 
plete when  the  entire  product  of  conception  is  expelled ;  incomplete  when 
a  portion  of  the  ovum  is  retained  in  utero  after  the  expulsion  of  the  fetus. 

For  the  purpose  of  this  discussion  the  subject  of  abortion  presents 
two  general  subdivisions,  non-induced  and  induced  abortion,  and  under 
the  latter  head  must  be  distinguished  legitimate  and  criminal  abortion. 


1.   NON-INDUCED   OR   SPONTANEOUS  ABORTION. 

The  frequency  with  which  miscarriage  occiu-s  from  innocent  causes  is 
variously  estimated  at  from  one  in  five  to  one  in  ten  pregnancies. 

The  causes  of  spontaneous  abortion  may  be  divided  into  two  groups : 
1.  Those  which  act  by  first  causing  the  death  of  the  fetus ;  2.  Those  which 
act  independently  of  the  death  of  the  fetus. 

B}'  far  the  larger  pro2)ortion  of  cases  are  included  under  the  fii-st 
head.  The  fetus  may  die  in  consequence  of  malformation,  tlisease,  me- 
chanical violence — as  falls  or  blows — maternal  toxemia  (e.g.,  carbonic- 
acid  poisoning,  saturnism,  alcoholism,  mercurialism,  iodism,  etc.),  excess- 
ive anemia,  pathological  conditions  of  the  chorion,  the  amnion,  the  cord, 
or  the  decidua.  Old  age  or  disease  in  the  father  is  an  occasional  cause. 
On  the  death  of  the  fetus  the  ovum  shrinks,  and,  as  a  rule,  is  expelled 
within  a  few  days  or  weeks  as  a  foreign  body. 

Under  the  second  head  are  included  reflex  irritation  of  the  uterus  (as 
by  stinnilating  rectal  injections,  irritation  of  the  maninuiry  glands,  and 
tlie  like),  emotional  excitement,  placenta^  pra?via,  epileptiform  convulsions 
from  uremia  or  other  cause,  carbonic-acid  poisoning,  hemori'hages  into 
the  placenta,  detention  of  the  uterus  in  the  pelvis  by  adhesions,  dis- 
placements of  the  uterus,  uterine  carcinoma.  In'dramnios.  multiple  preg- 
nancy, falls,  or  blows.  Congestion  of  the  pelvic  organs  due  to  cu-culatory 
obstruction  in  the  lungs  or  liver,  or  to  heart  disease,  violent  nniscular 
effort,  excessive  coitus,  etc.,  may  result  in  hemorrhage  into  the  placenta 
and  consequent  abortion.  These  causes  operate  ])rimarily  to  excite  con- 
tractions of  the  uterus  and  thus  the  ultimate  expulsion  of  its  contents. 

467 


468  ^   SYSTEM  OF  LEGAL  MEDICINE. 


2.    INDUCED   ABORTIOX. 

(a)  Legitimate  Abortion. — Under  certaiu  conditions  it  becomes  the 
duty  of  tlie  obstetrician  to  terminate  the  pregnancy.  As  a  general  rule 
artificial  abortion  is  justifiable  when  the  mother's  life  would  be  jeopard- 
ized by  the  longer  continuance  of  the  gestation.  The  conditions  in  which 
it  is  most  frequently  called  for  are  nephritis  and  uncontrollable  vomiting 
of  pregnane}'.  In  extreme  contraction  of  the  pelvis,  and  in  certain  cases 
of  marked  atresia  of  the  soft  parts  of  the  parturient  canal,  the  evacuation 
of  the  uterus  in  the  early  months  of  pregnancy  is  permissible,  on  election 
of  the  mother,  where  a  Csesarean  ojDcration  would  otherwise  be  necessi- 
tated if  the  case  were  allowed  to  go  to  term.  It  may  also  be  called  for 
in  placenta  pr^evia. 

The  induction  of  abortion,  when  required  for  scientific  reasons,  should 
be  undertaken  only  with  the  formal  assent  of  another  practitioner.  The 
physician  should  always,  for  his  own  protection,  associate  with  himself 
a  competent  consultant  in  the  management  of  the  case. 

Various  measures  have  been  used  for  provoking  abortion.  Among 
them  may  be  mentioned  the  puncture  of  the  membranes  and  the  partial 
separation  of  the  ovum  by  means  of  a  uterine  sound.  These  are  more 
especially  applicable  in  the  early  months ;  later  the  passage  of  a  flexible 
bougie,  and  the  injection  of  glycerin,  high  up  between  the  membranes  and 
the  uterine  wall,  are  recognized  methods.  Repeated  strong  applications 
of  faradism  or  galvanism  through  the  uterus  will  usualty  provoke  abor- 
tion at  any  stage  of  j)regnancy.  In  the  fii'st  two  or  three  months  a  good 
method  in  experienced  hands  is  the  dilatation  of  the  cer"\TX  and  the 
■evacuation  of  the  contents  with  a  curette  and  uterine  forceps.  A  skilled 
operator  can  easily  empt}^  the  gravid  uterus  in  this  manner  in  fifteen  to 
twent}^  minutes. 

(b)  Criminal  Abortion. — The  measiu-es  employed  to  procure  illegiti- 
mate abortion  are  of  two  kinds,  medicinal  and  mechanical. 

Medicinal  Pleasures. — Abortifacient  drugs  act  by  dii-ectly  or  indii-ectly 
exciting  uterine  contractions.  Among  the  reputed  abortifacients  are 
ergot,  borax,  cimicifuga  (blacksnake-root),  extract  of  cottonwood,  sa%'in, 
rue,  tansy,  wormwood,  apiol,  yew,  pennyroyal,  digitalis,  squills,  quinine, 
belladonna,  pilocarpine,  sarsaparilla,  hellebore,  labiu-num,  gi^ains  of  para- 
dise, guaiacum,  sodium  sahcylate,  oil  of  amber,  phosphorus,  strychnine, 
broom-fern,  lignum  vitae,  hoarhound,  camomile,  mugwort,  cantharides, 
juniper,  juice  of  bamboo  leaves,  milk-hedge,  and  other  euphorbiaceous 
plants,  chii^etta,  molline,  carrot  seeds,  sassafras,  arsenic,  corrosive  sub- 
limate, cyanide  of  potassium,  sulphate  of  copper,  iron,  and  drastic 
purgatives  such  as  aloes,  croton-oil,  elaterium,  Epsom  salts,  gamboge, 
liierapicra,  and  pilacotia;  carbonic  dioxide,  bisidphide  of  carbon,  and 
illuminating  gas,  by  inhalation,  are  also  recognized  abortives.  Some  of 
these  preparations  act  directly  to  induce  contractions  of  the  uterine  mus- 
cular fibers ;  such  agents  are  known  as  ecliolics.  Others  act  on  the 
vascular  system.  With  very  few  exceptions,  these  di*ugs  are  capable  of 
causing  abortion  only  when  the  ovum  has  an  insecui'e  attachment, 
if  at  all.  Wlien  they  operate  promptly,  at  least  in  ordinary  doses,  it  is 
to  be  presumed  that  there  was  a  predisposition  to  miscarry. 

Of  the  foregoing  agents  only  a  few  requii'e  special  mention. 


ABOllTIOX  AM)   IXFAXriCIDE.  4G9 

Ergot. — This  sul)stanee  is  a  nioi-Lid  growtli  sometimes  found  on  tlie 
seed  of  rye  and  certain  other  grasses.  The  ergot  of  rye  [Si'cale  coniufiini) 
is  that  most  commonly  employed.  Ergot  has  the  power  to  intensify 
uterine  contractions  alread}'  begun.  That  it  can  originate  them  de  novo, 
during  the  lii'st  half  of  pregnane}',  is  considered  doubtf  id ;  yet  I  have 
occasionally  seen  evidence  of  its  influence  as  an  ahortifacient,  even  in 
the  early  months  of  gestation.  The  dose  of  the  crude  drug  is  from  one- 
half  to  two  drams,  of  the  fluid  extract,  from  one  to  two  fluid  drams,  three 
times  daily.  lu  extreme  doses  ergot  gives  lise  to  toxic  effects.  A  sense 
of  heat  and  dryness  of  the  throat,  pains  in  the  stomach  and  bowels, 
nausea,  and  sometimes  diarrhea  are  the  principal  symptoms.  Occasion- 
idly  there  is  marked  retardation  of  the  cardiac  movements,  vrith.  headache 
and  vertigo,  delirium  and  coma.     The  pupils  are  usuall}-  dilated. 

Ergot  in  powder  has  a  faint,  fishy  odor  which  is  especially  developed 
by  rubljing  with  a  solution  of  potassic  hydrate.  The  same  odor  is  mani- 
fest on  mixing  the  caustic  potash  solution  -v^-ith  the  tincture  of  ergot, 
when  free  from  the  odor  of  other  substances.  When  ergot  has  been 
taken  in  powder  the  drug  may  usually  be  recognized  by  the  microscope 
as  small  red  particles  deposited  upon  the  mucous  membrane  of  the 
stomach  and  iutestiues. 

Tansy  {Tanacetumvnlfjare). — In  our  own  country,  especially,  this  agent 
has  a  popular  reputation  as  au  abortive.  The  oil  and  the  infusion  are 
the  preparations  most  frequentty  used.  Fatal  results  have  followed 
the  ingestion  of  a  half-oimce  of  the  oil,  and  even  smaller  quantities.  In 
a  case  mentioned  in  the  United  States  Dispensatory,  death  resulted  from 
a  large  dose  of  the  infusion  taken  internally.  The  toxic  symptoms  con- 
sist of  irregidar  respiratiou  and  extreme  cardiac  depression,  with,  finally, 
violent  convulsions  and  coma.     Abortion  does  not  necessarily  oecm-. 

Cotton-root  (root  of  the  Gossypium  herhaceiim,  or  common  cotton- 
plant). — The  tincture  or  decoction  of  the  bark  of  the  root  has  acquii-ed 
the  reputation  of  an  abortifacient,  and  is  said  to  be  used  for  this  pui-pose 
among  the  colored  race  of  the  Southern  States.  The  latter  statement, 
however,  has  lieen  denied  on  the  authority  of  reputable  Southern  practi- 
tioners. 

Savin  (the  tops  of  the  Juniperus  sahina). — The  oil  is  the  most  active 
preparation.  The  fluid  extract  is  nearly  as  effective.  The  powdered  leaf 
is  sometimes  employed,  as  are  also  the  infusion,  the  decoction,  and  the 
tincture.  The  medicinal  dose  of  the  powdered  leaf  as  an  emmenagogue 
is  ten  to  fifteen  grains,  of  the  tinctm-e  one-half  to  one  dram,  and  of  the 
oil  five  minims.  The  toxic  effects  are  severe  pain,  caused  l)y  its  irritant 
action  upon  the  stomach  and  intestines,  with  vomiting  and  diarrhea,  and 
finally  colic  and  convulsions.  Salivation  and  hematm-ia  are  also  com- 
mon results  of  the  ingestion  of  toxic  doses.  Its  action  upon  the  uterus 
is  probably  secondary  to  its  violent  systemic  effects,  and  the  tb-ug  is 
accordingly  an  exceedingly  dangerous  agent  when  used  in  quantities 
sufiicieut  to  produce  abortion.  It  can  be  said  to  have  no  specific  power 
as  an  abortive  agent. 

The  oil  is  recognized  by  its  yellowish  color  and  the  characteristic  odor 
of  the  plant.  It  is  solul)le  in  ether,  and  may  be  recovered  from  the  C(m- 
tents  of  the  stomach  by  shaking  them  in  a  flask  -with  this  agent.  After 
death  by  saviu-|»oisoning  the  odor  of  the  di'ug  is  sometimes  perceptible 
in  the  tissues  of  the  body. 


470  ^  syste:u:  of  legal  medicine. 

Eiie  {Rufa  graveolens). — Preparations  of  rue  have  a  decided  action; 
upon  the  utenis.  Most  used  are  the  powdered  leaf,  the  essential  oil,  and 
the  infusion.  The  medicinal  dose  is  one-half  to  one  dram  of  the  powder, 
fi'om  one  to  five  minims  of  the  oil,  and  from  five  to  thii'ty  grains  of 
the  leaf  in  infusion.  In  toxic  doses  it  produces  vertigo  and  is  a  power- 
ful vascular  depressant.  The  tongue  heconies  swollen  and  the  patient 
suffers  from  salivation,  nausea,  severe  pain  in  the  stomach,  jactitation, 
stupor,  and  chiUs.  The  abortive  effects  of  the  di'ug  are  usuallj^  developed 
only  after  marked  sj'stemic  disturbance.  The  contents  of  the  uterus  are, 
as  a  rule,  expelled  on  the  second  day  after  the  onset  of  the  toxic  symp- 
toms. 

Tew  {Taziis  haccata). — Abortive  properties  have  been  attributed  to 
the  fi'iiit  of  the  yew-tree,  but  in  all  recorded  instances  of  its  use  for  the 
purjiose.  death  has  taken  place  without  evacuation  of  the  utenis. 

Saffi'on  {Crocus  safivus). — The  stiginas  of  the  satfi-on  flowers  are  a 
popular  abortif a cient;  but  theii'  reijutation  as  a  uterine  excitant  appears 
to  have  no  foundation  in  fact. 

PennjToyal  {Hedeoma  pulegioides). — The  warm  iirEusion,  pennjToyal 
tea,  is  a  much-used  emmenagogaie  in  domestic  practice.  Its  re]3utationr 
however,  as  a  means  of  provoking  the  mensti'ual  flow  is  not  well  founded. 
Its  mention  here  would  be  unnecessaiy  but  for  the  fact  that  active  aborti- 
facient  properties  have  been  erroneously  attributed  to  it  in  a  noted  case' 
in  the  criminal  coui'ts  of  Cireat  Britain. 

Drastic  Cathartics. — Aloes,  croton-oil,  elaterium,  colocynth,  and  other- 
violent  pui'gatives  may  act  as  reflex  uterine  excitants.  Hiera-picra  (a 
combination  of  caneUa  bark,  one  part,  and  aloes,  four  j^aris)  and  pilacotia 
(a  mixtru'c  of  coloc^Tith  and  aloes)  are  sometimes  employed  as  abortives. 
This  class  of  agents  are  of  httle  effect  as  abortif acients  except  hi  condi- 
tions which  predispose  to  miscarriage. 

Apiol  is  an  emmenagogue  of  undoubted  power.  It  exerts  a  dh-eet 
effect  upon  the  circulation  of  the  uterus.  It  is  therefore  capable  of  ex- 
citing abortion  under  fa^'orable  circumstances. 

The  tinctiu'e  of  the  chloride  of  h'on  has  been  given  in  large  doses  with 
the  intent  of  producing  abortion.  While  it  is  caxiable  of  deleterious 
effects  upon  the  general  health  when  used  in  large  quantities,  it  has  no 
specific  action  as  an  abortifacient. 

Meclianical  Measures. — Mechanical  measures  are  far  more  effectual 
abortives  than  drugs.  These  means  ma\',  after  the  first  two  or  three 
months  of  gestation,  be  such  as  act  by  fii'st  causing  the  death  of  the 
fetus.  Thus  the  child  may  be  kiUed  b}^  blows  upon  the  inothei*'s  ab- 
domen. Generally  direct  "siolence  to  the  abdomen  produces  abortion  by 
disturbing  primarily  the  relation  of  the  ovum  to  the  utenis.  The  at- 
tachment of  the  ovimi  to  the  uterine  wall  is  jiartially  broken  up,  with  the 
effect  to  bring  on  expulsive  efforts  of  the  uterus. 

Under  this  head  are  included  blows  on  the  abdomen,  intentional  falls 
and  muscular  strains,  caiTiage-riding  over  rough  roads,  bareback  riding,. 
long  walks,  tight-lacing,  vaginal  or  uterine  douches,  and  direct  inteifer- 
ence  by  other  means  within  the  uterus.  Tents  of  sponge,  sea-tangle,  or 
similar  material  are  probablj'  seldom  used  by  criminal  abortionists. 
These  instruments  consist  of  small,  compact  pencils  of  sponge  of  wood 
about  two  inches  in  length,  which  possess  the  property  of  expanding 
when  moist.     Placed  in  the  canal  of  the  uterine  neck  they  absorb  water 


ABOUTIOX  AM)   IXFASTIVJDE.  471 

from  the  sniTOiiiidiii^  structures,  aud,  swelling-,  tliey  dilate  the  cervix. 
The  ovum  is  i)artially  separated  from  its  attacliments  at  the  lower  seg- 
meut  of  the  uterus,  and  becoming  in  part  a  foreign  body,  the  uterus  con- 
tracts to  expel  it. 

The  methods  most  employed  are  some  forms  of  direct  interference. 
The  ovimi  nuiy  be  partially  detached  from  the  lower  uterine  segment  by 
means  of  a  sound  or  probe,  or  it  may  be  pei-forated.  In  the  first  method 
the  curved  uteiine  sound  is  passed  between  the  membranes  and  the  ute- 
I'ine  wall,  and  the  memljranes  peeled  up  l)y  sweeping  the  point  of  the 
sound  around  the  circle.  Uterine  contractions  may  thus  be  set  up  gen- 
erally within  a  few  hours.  When  abortion  is  induced  by  penetrating 
the  membranes  a  blunt  probe  or  pointed  instrument  is  passed  through 
the  neck  of  the  uterus  and  the  membranes  perforated.  This  operation 
is  done  by  the  professional  abortionist  and  sometimes  by  the  patient  her- 
self. The  attempt  is  less  likely  to  be  successful  in  proportion  as  the 
stage  of  gestation  is  early  and  the  ovum  small.  Among  the  instruments 
that  have  been  used  for  this  purpose  by  the  woman  herself  may  be  men- 
tioned knitting-needles,  pieces  of  wdre  or  whalebone,  stilettos,  hairpins, 
penholders,  l)ougies  or  catheters,  and  wooden  skewers;  sometimes  the 
finger.  The  professional  abortionist  generally  employs  a  uterine  sound 
or  some  similar  appliance  as  a  perforator.  On  puncture  of  the  mem- 
branes the  liquid  contents  of  the  ovnm  escape  and  the  ovum  collapses, 
the  uterus  retracts,  partially  separating  the  product  of  conception  from 
its  attachments  to  the  uterine  wall,  aud  a  greater  or  less  amount  of  hem- 
orrhage occurs.  The  embryo  or  fetus  dies  from  beginning  interruption 
of  the  uteroplacental  circulation  and  other  causes,  and  the  uterine  con- 
tents become  a  foreign  body.  As  a  rule  contractions  of  the  uterus 
are  soon  established,  and  it  exj)els  its  contents  generally  within  a  few 
<lays.  The  final  expulsion  of  the  ovnm  may,  however,  be  delayed  for  a 
week  or  more.  Frequently  the  case  terminates  fatally  by  peritonitis  or 
general  sepsis.  While  in  properly  conducted  aboi-tion  the  death-rate  is 
practically  nil,  the  mortality  of  criminal  aboi-tion  is  very  great.  This  is 
due  to  the  fact  that  in  abortion  done  by  the  woman  herself  or  by  an 
unskilled  abortionist  portions  of  the  product  of  conception  are  usually 
left  to  putrefy  in  the  uterine  cavity.  Often,  too,  the  wonum  is  infected 
primarily  by  unclean  instruments  and  methods  of  operating.  Moreover, 
unnecessary  violence  is  frequently  done  to  the  uteriue  walls.  The  point 
•of  infection  is  often  a  wound  of  the  uterus  made  by  the  instrument. 
Many  cases  have  been  reported  in  which  the  woman,  in  her  desperate  de- 
termination to  put  an  end  to  the  pregnancy,  had  passed  a  knitting-needle 
or  similar  appliance  through  the  posterior  vagiual  fornix  or  the  uterus 
into  the  peritoneal  cavity.  Bodies  of  this  description  have  sli])i)ed  wholly 
into  the  (cavity  of  the  abdomen  and  l)een  subsequently  removed  by  abdom- 
inal section.  Such  injuries  to  the  peritoneum  usually  i-esult  in  death 
by  peritonitis.  More  scientific  methods  sometimes  resorted  to  by  expert 
ai)ortionists  ai-e  intra-uterine  injections  or  the  mechanical  dilatation  of 
the  cervix  uteri. 

The  galvanic  or  faradic  current  is  sometimes  employed  to  excite  ex- 
pulsive efforts.  This  method  is  frequently  effectual  wlien  strong  currents 
are  passed  directly  through  the  utei'us.  One  electrode  is  placed  in  the 
vagina  against  the  cer^vix  or  is  passed  "\^'ithin  the  uterus,  aud  the  other 
rests  on  the  lower  abdomen  or  back.     These  agents  act  by  inducing  ute- 


472  ^   SYSTEM  OF  LEGAL   MEDICINE. 

rine  contractions,  or  possibly,  Tvlieu  hea^y  cnrrents  are  employed,  l3y  fii'st 
causing  the  death  of  the  fetus. 

CLINICAL   EVIDENCE   OF   RECENT  ABORTION. 

The  amount  and  character  of  the  medical  evidence  on  which  the  proof 
of  abortion  depends  differ  mth  the  stage  of  gestation,  and  with  the  time 
that  has  elapsed  since  the  uterus  was  emptied. 

Genital  Discharges. — For  at  least  one  or  two  weeks  after  miscarriage 
at  an}^  stage  of  pregnancy  there  is  a  more  or  less  abundant  lochial  flow. 
Flooding  or  the  existence  of  a  fetid,  bloody  vaginal  discharge  shoidd 
arouse  suspicion.  These  signs,  however,  in  the  liA-ing  subject,  disappear 
within  a  short  time  after  abortion  in  the  early  months  of  gestation,  and 
are  rarely  sufficiently  marked,  after  one  or  two  weeks  have  elapsed,  to  be 
of  much" value  as  e^ddence  that  pregnancy  has  existed. 

When  the  product  of  miscarriage,  or  any  portion  of  it,  is  available  for 
examination  the  question  presents  little  or  no  difficulty.  Blood-clots 
which  have  been  expelled  from  the  uterus  iu  the  early  months  of  sup- 
posed pregnancy  should  be  broken  up  under  water  and  carefid  search 
made  for  shreds  of  fetal  membranes  and  fragments  of  placental  tissue. 
The  gross  characters  of  the  product  of  conception  are  usually  sufficient 
for  its  identification.  When  doubt  exists,  it'  the  specunen  has  not  been 
too  much  altered  by  decomposition,  examination  by  the  microscope  will 
decide.  The  discovery  of  fetal  ^illosities  in  the  material  cast  off  by  the 
uterus  is  conclusive  evidence  that  the  case  was  one  of  pregnancy.  In  the 
first  two  mouths  the  emliryo  is  seldom  f  oimd.  It  is  either  lost  in  the  dis- 
charges or  has  disappeared  by  absorption  before  expidsion  of  the  uterine 
contents.  Its  tissues  at  this  early  stage  of  development  are  so  soft  that 
they  are  rapidly  broken  down  after  its  death,  and  are  promptly  aljsorbed 
or  washed  away  in  the  discharges.  Even  when  the  o^iim  has  been  ex- 
pelled and  lost,  chorial  \'illosities  may  usually  be  obtained  by  curetting 
the  uterine  cavity  within  a  few  days  after  the  abortion.  By  the  end  of  a 
week  after  the  expulsion  of  the  uterine  contents  the  search  for  fetal 
structures  in  the  uterus  ^^ill  seldom  lie  successful.  At  the  thii'd  month, 
and  later,  the  development  of  the  fetus  is  such  that  it  constitutes  a  con- 
spicuous part  of  the  product  of  conception. 

Condition  of  the  Uterovaginal  Tract. —  The  uterus  remains  some- 
what enlarged  for  at  least  two  or  three  weeks  after  alwrtiou  at  any  stage 
of  pregnancy,  and  its  stractm-e  is  for  a  time  somewhat  less  dense  than 
is  normal  to  the  non-gravid  uterus.  The  cer^dcal  canal,  too,  is  more 
patidous.  The  growth  of  the  uterus  is  greater  with  each  succeeding  month 
of  gestation,  and  its  involution  after  labor  in  advanced  pregnancy  occu- 
pies a  greater  length  of  time  than  after  aliortion  in  the  earlier  mouths. 
For  two  or  three  weeks  after  delivery  at  or  near  term,  the  vagina  remains 
enlarged  and  relaxed,  and  more  or  less  extensive  tears  are  to  be  found 
.  about  the  vaginal  orifice.  These  injuries  are  more  conspicuous  in  primi- 
parae  than  in  multipara?.  The  stage  of  repair  ^\^\i  correspond  with  the 
length  of  time  that  has  elapsed  since  the  birth.  Abortion  in  the  early 
months  leaves  no  similar  traces  in  the  lower  portion  of  the  genital  tract. 

Other  Changes  in  the  Maternal  Organism  During  Pregnancy. — 
Before  the  end  of  the  third  month  of  gestation  the  changes  which  take 
place  in  other  than  the  pelvic  organs  in  consequence  of  pregnancy  are 


Plate    im    VI. 


Fig.A. 


;•     \^ 


^. 


«     * 


f      J 


.1*- 


n 


*,,  *«-• .. 


Fig.B. 


Fig.  A — Lungs  and  intrathoracic  organs   of  a  new  born  child  at  term, 
having  lived  and  respired,  who  was  the  victim  of  infanticide  by   suffocation. 
C  Fig.  ^^|— Spot  of  Meconium  found  on  cloth. 
B  Fig.  (j|— Spot  of  Foetal  Coating  (enduit  foetal  Tardieu). 


GAST  IITH  CO.N.' 


ABORTION  AND   INFANTICIDE.  475 

few  and  imperfectly  developed,  and  they  recede  more  or  less  within  a 
few  daiys  after  niiscan"ia,i2:e.  They  are  of  praetically  no  diafjnostic  vaiue 
in  pre}4'uan('ics  siibscMjucut  to  tlie  first,  since  niany  of  the  elian^^'s  induced 
by  pi'cu-nniic}^  i-cTiiain  in  a  measure  permanent.  Tlie  size  and  fii-mness  of 
the  maiiiiiiary  glands  will  be  found  increased  from  tlie  end  of  the  second 
month  of  jij-estation.  The  increased  ])ig'mentation  of  the  majumary  ai'colu', 
and  the  pigmented  line  extending-  from  the  ])ube.s  to  the  umbilicus,  ex- 
cept in  light-complexioned  subj(;cts,  are  per(;eptil>le  by  the  second  month. 
By  this  time,  too,  the  veins  over  the  surface  of  the  breasts  have  beconjc 
turgid,  and  by  eh^se  insi)ecti()n  may  be  seen  coursing  across  the  primary 
areohi?.  After  the  third  month  a  milky  serum  may  generally  be  pressed 
from  the  nipples.  Practically  all  these  (ihanges  may  occur  as  the  result 
of  pelvic  disease,  whi<'h,  thercfoi-e,  must  be  excluded. 

Evidence  Afforded  by  Stains  upon  the  Bedding  or  Clothing. — 
Blood  discharged  from  a  woman  in  case  of  abortion  is  practically  indis- 
tingaishable  from  human  blood  derived  from  other  sources. 

Meconium  stains  present  certain  distinctive  characters  by  which  they 
may  usually  be  identified.  This  material  is  a  dark- greenish,  viscous  liquid 
yielding  the  reaction  of  bile  to  the  nitric-acid  test.  With  tincture  of 
iodine  a  green  coloration  is  produced.  Among  its  microscoj^ical  elements- 
are  intestinal  epithelium  and  crystals  of  cholesterin.     (Plate  VI.,  Fig.  C.) 

In  case  of  abortion  in  an  advanced  stage  of  pregnancy  vernix  caseosa 
may  be  found  on  the  i)atient's  linen  or  bed-linen.  This  material  may  be 
identified  by  its  microscopic  and  chemical  characters.  The  microscope 
reveals  epidermic  scales  and  lanugo.  The  presence  of  fatty  matter  is 
demonstrated  bv  shaking  ujd  the  particles  with  ether,  which  extracts  the 
fat.     (Plate  VI.;  Fig.  B.) 

POST-MORTEM   SIGNS   OP   RECENT   DELIVERY. 

All  the  clianges  in  the  maternal  organism  which  may  result  from 
pregnancy  should  be  looked  for.  The  evidence  of  recent  delivery,  how- 
ever, is  to  be  found  mainlj^  in  the  condition  of  the  vagina  and  the  uterus. 
The  vagina  is  increased  in  size,  and,  after  delivery  in  the  later  months  of 
pregnancy,  its  outlet  presents  the  wounds  or  cicatrices  characteristic  of 
recent  childbirth. 

The  uterus  is  enlarged  according  to  the  stage  of  gestation  wliich 
had  been  reached  and  tlie  degree  of  involution  which  had  taken  place. 
Immediately  after  delivery  at  term  the  uterus  measures  externally 
7  or  8  inches  in  length,  and  4  or  5  in  width  at  the  level  of  the  Fal- 
lopian tubes.  The  thickness  of  the  walls  is  about  \h  inches.  The  depth 
of  the  cavity  is  at  the  close  of  labor  G  inches  ;  at  the  end  of  the  first  week 
about  4.J  inches ;  at  the  end  of  the  second  week  Z]^  inches ;  and  al)out  3^ 
inches  at  the  expiration  of  a  mouth.  The  fundus  uteri,  shortly  after 
labor,  lies  at  the  level  of  the  umbilicus ;  by  the  tenth  day  at  the  pelvic 
brim. 

The  average  weight  of  the  uterus  at  the  close  of  a  fuU-term  labor  is 
35  ounces;  at  the  end  of  the  first  week,  16  ounces;  at  the  end  of  the 
second  week,  12  ounces ;  end  of  the  third  week,  8  ounces.  The  uterus 
does  not  usuaUy  fully  regain  its  normal  dimensions  for  nearly  two 
months.  The  regressive  process  is  somewhat  slower  in  nndtipara^  than 
after  first  labors.     The  cervix  remains  relaxed  and  soft  after  labor,  begin- 


476  ^  systjlM  of  legal  medlcixe. 

iiiug  to  regain  its  form  and  consistence  after  about  twelve  hours ;  two 
fingers  can  be  passed  tlu-ough  the  os  internum  at  the  end  of  twenty-foiu' 
hours.     At  the  expii-ation  of  a  week  the  cervical  canal  admits  one  finger. 

Dii'ectly  after  dehvery  the  canity  of  the  uterus  is  still  lined  with  the 
outer  layer  of  decidua  and  ^vith  shreds  of  the  inner  layer.  The  placental 
site  presents  a  shghtly  elevated  and  uneven  sm^faee  studded  with  thrombi 
lying  in  the  mouths  of  the  uteroplacental  vessels,  winch  have  been  torn 
across  b}^  the  separation  of  the  placenta.  More  or  less  fluid  and  clotted 
blood  is  jDresent  in  the  ca^dty.  The  muscular  fibers  of  the  full-term 
uterus  ai'e  from  seven  to  eleven  times  longer  than  in  the  normal  state 
of  the  non-gi'avid  organ,  and  are  increased  in  thickness.  These  changes 
in  the  uteras  will  have  receded  in  proportion  to  the  length  of  time  that 
has  elapsed  since  confinement,  and  will  vary,  too,  "with  the  degree  of  pre- 
matnrity  of  the  bii"th. 

The  presence  of  a  coi-pus  luteum  in  the  ovary  is  not  distinctive 
of  pregnancy.  A  corpus  luteum  is  found  whenever  an  ovum  has 
been  recently  discharged  from  the  ovary.  It  is  always  to  be  observed 
during  the  fii'st  two  or  three  weeks  after  menstruation.  It  reaches  a 
higher  degi'ee  of  development  dm-ing  pregnancy  and  does  not  disappear 
for  several  weeks  after  childbii-th.  The  absence  of  the  usual  corpus 
luteum  of  menstruation  in  its  recent  state  would  be  e^ddence  that  a  period 
of  at  least  many  weeks  had  elapsed  since  the  last  menstrual  flow. 

AT  WHAT  STAGE  OF  GESTATIOX  HAS  THE  ABORTION  TAKEN  PLACE  ? 

The  stage  of  pregnancy  at  which  abortion  has  taken  place  must  be 
estimated  from  the  measurements  of  the  uteiiis,  and  from  the  size  and 
development  of  the  fetus  when  the  latter  is  available  for  examination. 

The  following  table  shows  the  dimensions  of  the  uterus  while  it  still 
contains  the  li-^dng  ovum,  at  different  periods  of  gestation : 

SIZE   OF   THE   UTERUS. 


Stage  of 

Gestation. 

Lengtli. 

Width. 

3d  month. 

5  inches. 

4  inches 

4th 

a 

6 

5         " 

5th 

ii 

7 

6         " 

6th 

11 

8i 

6i       " 

7th 

a 

10 

7         " 

8th 

11 

Hi 

8         " 

9th 

ii 

13 

9         " 

10th 

a 

14 

10 

The  measiu'ements  of  the  uterus  are  considerably  diminished  after  ex- 
pulsion of  its  contents,  yet  the  foregoing  figures  may  serve  as  a  guide  in 
estimating  the  period  of  pregnancy  at  which  a  miscarriage  has  taken 
place. 

The  nuUiparous  uterus  is  nearly  1  inch  in  thickness,  l-i  inches  in 
width  at  the  fundus,  aud  2^-  in  length ;  it  weighs  about  1  ounce.  The 
parous  uterus  in  the  non-gTa"\'id  subject  is  approximately  1  inch  thick,  2 
inches  wide,  and  3  inches  long,  and  its  weight  is  1.^  ounces. 

The  uteras  at  the  close  of  labor  at  term  weigiis  about  35  oimces. 


Aiioirrios  AMI  iMAMiriDi:.  477 

Development  of  the  Fetus. — The  length,  weif>'lit,  and  development 

of  the  fetus  at  different  .stages  of  gestation  are  as  follows: 

At  the  end  of  the  first  lunar  month  the  diameter  of  the  ovum  is  f  of 
an  inch.  The  ehorial  villi  are  developed  over  the  entire  sui-faee  of  the 
ovum.  The  eml)ryo  measures  ^  of  an  inch  in  length  and  weighs  15 
grams.  The  nose  and  mouth  form  one  cavity,  the  abdomen  is  still 
open,  the  umbilical  vesicle  persistent,  and  the  mendjers  are  indicated  l>y 
mere  })a})illa3. 

At  the  end  of  the  second  month  the  ovnui  is  2h:  inches  in  diameter ; 
the  chorionic  villosities  have  l.)egun  to  disappear  over  two  thirds  of  its 
surface.  The  length  of  the  endjryo  is  1-^  inches,  and  its  average  weight 
is  1  dram.  The  mouth  and  nose  are  sej^arate  and  the  al)domen  closed. 
The  umbilical  vesicle  clisa,ppears.  The  meml)ers  are  formed,  but  the 
fingers  and  toes  are  webbed.  Ossification  is  beginning  in  the  inferior 
maxilla  and  in  the  clavicle. 

At  the  end  of  the  third  month  the  diameter  of  the  ovum  is  4  inches. 
The  placenta  is  formed.  The  embryo  is  S^-  inches  in  length  and  weighs 
1  ounce.  The  fingers  and  toes  are  separated;  the  sex  is  discernible. 
There  are  points  of  ossification  in  the  bones  of  the  skull  and  the  limbs. 
The  length  of  the  umbilical  cord  is  2i|  inches. 

At  the  end  of  the  fourth  month  the  fetus  measiu*es  5  inches  in  length 
and  weighs  about  3  ounces.  Hair  begins  to  appear ;  the  sex  is  clearly 
apparent ;  nails  begin  to  be  formed. 

At  the  end  of  the  fifth  month  the  length  of  the  fetus  is  9  inclies,  and 
its  average  weight  9^-  ounces.  The  umbilical  cord  is  about  1  foot  in 
length ;  its  point  of  insertion,  instead  of  being  at  the  symph^-sis  as  it 
is  till  the  fourth  month,  begins  to  move  upward.  Meconium  is  present  in 
the  intestines.  Vernix  caseosa  appears  for  the  first  time.  Ossification 
begins  in  the  ischium. 

At  the  end  of  the  sixth  month  the  fetus  is  12  inches  in  length  and 
weighs  about  23  ounces.  The  cord  measures  14^  inches.  Ossification 
begins  in  the  pubic  bones. 

At  the  end  of  the  seventh  month  the  fetus  is  14  inches  long  and 
weighs  about  2^  pounds.  The  average  length  of  the  cord  is  16^  inches. 
Ossification  has  begun  in  the  astragalus. 


E^T:DENCE   of   CREVnNAL  ABORTION. 

It  will  seldom  be  possible  to  determine  by  examination  of  the  pelvic 
■organs,  the  fetus,  or  its  appendages  whether  the  al)ortion  has  been  spon- 
taneous or  the  result  of  criminal  interference.  When  the  operation  has 
been  clumsily  done  the  marks  of  violence  may  be  sufficiently  ol)vious 
in  the  living  patient,  and  especially  on  examination  after  death,  to  estab- 
lisli  the  fact  that  criminal  measures  have  been  employed.  The  obvious 
presence  of  disease  in  the  membranes  or  placenta  would  point  to  the 
probability  that  the  abortion  was  spontaneous.  In  criminal  abortion  the 
product  of  conception  is  more  likely  to  be  mutilated  than  entire. 

The  history  of  the  woman's  illness  shoidd  be  carefull,y  analyzed  for 
the  toxic  symptoms  of  the  medicinal  agents  commonly  employed  for 
producing  abortion.  In  post-mortem  cases  the  contents  of  tlie  stomach 
and  bowels  should  be  examined  for  evidence  of  the  presence  of  abortive 


478  ^   SYSTJEM  OF   LEGAL    MEDICINE. 

dinigs.  The  abortive  agents  of  tliis  class  which  are  usuaUv  employed  are 
generally  capable  of  recognition  b}^  their  niicroscoj)ic  or  chemical  char- 
acters or  by  experiments  upon  animals. 


EVIDENCE    THAT    COXFINE^IENT   HAS   AT   SOjME   TDIE   TAKEN   PLACE. 

It  may  devolve  npon  the  medical  witness  to  distinguish  between  the  pa- 
rous and  the  nulliparous  condition — in  other  words,  to  determine  whether 
the  woman  has  ever  been  confined.     The  signs  are  general  and  local. 

The  j)igmentary  changes  which  take  place  upon  the  breasts  and  abdo- 
men during  the  first  pregnancy  remain  in  a  measui-e  permanent.  They 
are  usuall}^  well  marked  in  brunettes,  but  not  so  in  women  of  light  com- 
plexion. Moreover,  they  are  not  wholly  reliable  as  evidence  of  pregnancy^ 
since  similar  changes  may  occur  as  a  result  of  pelvic  disease.  The  irreg- 
ular whitish,  pinkish,  or  bluish  lines  which  are  developed  over  the  lower 
half  of  the  abdomen  after  the  sixth  month  of  pregnancy,  once  formed, 
are  never  effaced.  They  are  also  produced  by  abdominal  enlargement 
to  the  same  degree  from  other  causes,  yet  this  source  of  error  raQ.j  be 
easil}^  ehminated. 

The  principal  signs  are  to  be  sought  in  the  condition  of  the  organs 
immediately  concerned  in  the  pregnancy  and  the  birth.  Cicatrices  of 
old  lacerations  may  be  found  about  the  vulvar  orifice.  The  presence 
of  true  carunculae  myi'tiformes  may  be  taken  as  evidence  of  childbii-th. 
This  condition  must  be  distinguished,  however,  from  mere  rupture  of  the 
hymen.  The  carunculae  consist  of  four  or  five  small,  fleshy  excrescences 
skirting  the  vaginal  orifice,  and  which  represent  the  remains  of  the 
h^onen  torn  by  the  birth  of  the  child.  After  delivery  during  the  fii'st  half 
of  pregnancy  the  condition  of  the  hpnen  would  not  be  sufficiently  char- 
acteristic to  be  of  value  as  evidence  that  confinement  had  taken  place. 

The  vulva  and  vagina  are  more  relaxed  in  the  parous  than  in  the 
nulliparous  woman.  Vaginal  cicatrices  may  result  from  labor.  Reliable 
evidence  of  previous  childbirth  is  usually  afforded  by  the  condition  of 
the  cervix  uteri.  The  lower  border  of  the  uterine  neck  is  always  more 
or  less  notched,  and  sometimes  deeply  fissured,  after  labor  at  or  T^•ithin 
two  or  three  months  of  term.  The  uterus  remains  permanently  larger. 
Whether  the  number  of  confiuements  which  have  taken  place  is  one  or 
more  cannot  be  determmed  1\v  the  j^hysical  signs. 

It  is  seldom  possible  to  decide  whether  an  abortion  has  at  any  remote 
time  occm-red  in  the  early  months  of  pregnancy.  The  signs  are  fewer 
and  less  perfect^  developed  than  after  delivery  in  the  later  months,  and 
the  solution  of  the  question  is  the  more  difficult  the  earlier  in  pregnancy 
the  abortion  has  taken  place. 

FEIGNED    ABORTION. 

For  the  pm'pose  of  incriminating  others  a  woman  may  simulate  abor- 
tion. Taylor  relates  a  case  in  which  a  Avoman  in  Guy's  Hospital  accused 
a  policeman,  who,  she  alleged,  had  ravished  her,  of  having  procured  an 
abortion  by  means  of  drugs  which  he  had  administered  and  by  the  use 
of  local  mechanical  measures.  On  examination  by  a  medical  expert,  two 
months  after  the  alleged  miscarriage,  no  evidence  was  found  that  she  had 


ABORTION   AM>    I M'AM'iri Dil.  47(> 

ever  ])een  prej^uant.  Pi-iinarily  ^rave  doubt,  as  the  author  observes,  is 
cast  ii[)on  a  chargt,^  of  tliis  kind  wlieii  so  h)iig'  dehiyed  after  the  allej^ed 
fact. 

Of  interest  in  connection  with  this  subject  is  a  case  of  assumed 
abortion  which  was  recently  l)rought  to  public  notice  in  Brooklyn.  A 
gynecologist  of  recognized  al)ility  and  unblemished  reputation  was  ar- 
rested on  the  charge  of  criminal  abortion.  The  woman,  who  had  become 
ill  during  his  treatment,  joined  in  the  accusation,  under  the  belief,  which 
was  shai-ed  by  her  usual  medical  attendant,  that  she  had  miscarried  and 
was  about  to  die  of  peritonitis.  On  examination  1)y  the  waiter  she  was 
found  to  be  still  pregnant,  at  about  the  second  month,  with  no  evidence 
that  violent  measures  had  been  emploj^ed.  On  investigation  before  the 
coroner  the  gynecologist,  whose  treatment  was  show^n  to  have  been  en- 
tirely innocent  and  proper,  was  fully  exonerated. 


INFANTICIDE. 

The  term  infanticide  as  used  in  medical  jurisprudence  appUes  to  the 
murder  of  a  new-born  child.  In  the  vast  majority  of  cases  the  crime  is 
coTumitted  at  birth  or  directly  after.  It  is  immaterial,  however,  whether 
tlie  age  of  the  child  is  measured  by  minutes  or  days,  since,  under  our 
law,  "it  is  equally  murder  to  destroy  the  life  of  a  child  which  has  been 
completely  born  as  it  would  he  feloniously  to  kill  an  adult."  Nor  is  it 
necessary  that  the  child  shall  have  reached  the  full  term  of  intra-utei-ine 
development,  pro^dded  it  has  lived  after  its  bu-th.  It  mast,  however, 
have  been  fully  expelled  in  a  living  condition.  It  does  not  matter  whether 
the  cord  has  been  divided  or  not ;  the  child  is  born  when  it  has  been 
completely  expelled  from  the  maternal  passages  even  though  the  cord 
be  still  intact.  It  may  have  been  born  alive  even  though  it  had  never 
breathed.     Death  takes  place  only  when  the  heart  ceases  to  beat. 

The  destruction  of  a  child  in  ntero  or  in  course  of  birth  is  not  infan- 
ticide. 

The  law  assumes  that  every  new-born  child  has  been  born  dead  until 
the  contrary  is  proved.  The  burden  of  proof  that  the  life  of  the  child 
has  been  willfully  destroyed  is  cast  upon  the  prosecution.  This  is  a  benefi- 
cent provision  of  the  law  to  prevent  unjust  con^•iction,  and  is  rendered 
necessary  by  the  fact  that  a  large  number  of  children  are  at  birth  dead 
or  non-vicil)le.  It  will  thus  be  seen  that  the  problem  presented  to  the 
medical  jurist  in  a  case  of  alleged  infanticide  is  l\v  no  means  a  simple 
one ;  sometimes  it  is  beyond  the  reach  of  medical  e^'idence. 

Adopting  the  scheme  of  Ogston,  the  questions  which  confront  the 
expert  are  the  following : 

1.  Has  the  prisoner  been  recently  delivered? 

2.  Was  the  child  inature  ? 

3.  Was  it  the  child  of  the  prisoner? 

4.  Was  it  dead  or  alive  at  its  l)irtli  ? 

5.  If  alive,  what  was  the  cause  of  its  death? 


480  ^   SYSTEM  OF  LEGAL  MEDICIXE. 


1.    HAS   THE   PEISONER   BEEX   RECENTLY   DELRT:EED  ? 

The  facts  upon  Trhicli  tlie  solution  of  this  question  -vrill  depend  have 
"been  ah-eady  considered  under  Abortion. 

The  question  may  arise  in  this  connection  whether  a  woman  who  has 
just  been  coniined  could  be  ignorant  of  the  fact.  That  a  woman  may 
give  bu'th  to  a  child  without  knowing  it  and  without  having  recognized 
the  existence  of  pregnancy  is  scarcely  to  be  presumed.  She  may,  how- 
ever, be  unexpectedly  delivered.  In  very  rare  cases  the  labor  is  practi- 
cally painless,  and  the  child  may  be  born  before  the  mother  is  aware 
that  the  labor  has  actively  begun.  Again,  the  termination  of  the  bii-th 
is  frequently  abrupt :  the  child  is  sometimes  expelled  from  the  uterus 
into  the  world  in  a  single  pain.  This  is  more  hkely  to  occm-  if  the  wom- 
an is  in  an  upright  postm-e.  A  child  expelled  while  the  mother  is  in  a 
standing  or  sitting  position  may  sustain  serious  injury  by  precipitation 
upon  the  floor  or  into  a  water-closet.  Yet  simple  falls  are  seldom  fatal : 
the  distance  is  short  and  the  fall  may  be  partly  broken  by  the  cord. 

Unintentional  precipitation  of  the  child  into  a  water-closet  or  priws^ 
vault  may  easily  happen  and  is  not  an  extremely  rare  occui-rence.  The 
pressure  of  the  presenting  part  of  the  fetus  in  the  lower  portion  of  the 
birth  canal  usually  gives  rise  to  a  \dolent  rectal  tenesmus.  The  sensa- 
tion is  mistaken  for  an  ui'gent  demand  for  stool.  Eesponding  to  the 
seeming  necessity,  the  upright  position  of  the  partmient,  and  the  strain- 
ing, help  to  precipitate  the  birth,  and  in  this  way  it  can  happen  that  the 
child  may  be  di'opped  into  a  water-closet  consistently  with  the  entire  in- 
nocence of  the  mother.  Unconscious  delivery  is  of  eoiu'se  possible  iti 
eclampsia,  in  coma  from  whatever  cause,  and  under  aneesthesia. 


2.    WAS   THE    CHELD   ]\LA.TURE  ? 

The  probability  of  natural  death  in  the  new-born  is  gTcater  in  propor- 
tion to  the  prematurity  of  the  birth.  The  medical  witness  will  therefore 
be  required  to  testify  to  the  probable  stage  of  intra-uterine  development 
which  the  child  had  reached. 

The  following  are  the  data  upon  which  an  approximate  estimate  may 
be  given  in  the  last  three  mouths  of  fetal  development.  For  the  rate  of 
fetal  gTOwth  in  the  preceding  months  the  reader  is  referred  to  page  477. 

At  the  eighth  lunar  month  the  average  fetus  measures  IG  inches  in 
length  and  weighs  3.J  pounds.  The  nails  are  fully  developed,  but  do  not 
project  beyond  the  finger-tips.   Lanugo  begins  to  disappear  from  the  face. 

At  the  ninth  lunar  month  the  fetus  is,  approximate^,  17  inches  in 
length,  and  its  weight  about  4  pounds.  .  Lanugo  is  beginning  to  dis- 
ai)pear  from  tbe  Iwdy.  The  ossific  nucleus  in  the  lower  femoral  epiph- 
ysis first  becomes  visible. 

At  the  tenth  lunar  month,  the  period  of  fuU  maturity,  the  height  of  the 
child  is  from  18  to  20  inches.  The  measure  is  to  he  taken  from  the 
vertex  to  the  lower  border  of  the  calcaneum.  The  a^^erage  weight  is  7 
pounds. 

The  principal  head  diameters,  subject  to  certain  modifications  due  to 
molding  when  measured  shortly  after  birth,  are  as  f oUows :  The  bipari- 


ABORTIOX  AND   IXFAXTICIDE.  481 

etal,  measured  tlirough  tlie  parietal  eiuiueiices,  3^  iiiclies ;  the  fronto-iuen- 
tal,  from  the  summit  of  the  forehead  to  the  center  of  tlie  h)wer  mai'^nu 
of  tlie  chin,  8.i  inches;  the  occipito-frontal,  from  the  tip  of  the  o('('ii)ital 
protuberance  to  the  root  of  the  nose,  4J  inches ;  the  occipito-raental,  from 
the  tip  of  the  occipital  protuberance  to  the  center  of  the  lower  margin  of 
the  chin,  5|  inches ;  the  suboccipito-bregmatic,  from  the  junction  of  the 
nucha  and  occiput  to  the  center  of  the  breg-ma,  3^  inches ;  the  l)item})oral, 
the  distance  l)etvveen  the  lower  extremities  of  the  coronal  sutures,  3^ 
inches ;  the  bimastoid,  the  greatest  distance  between  the  mastoid  ai)Oijhy- 
ses,  2|  inches.     The  length  of  foot  is  3J  inches. 

Tlie  average  weight  of  the  new-born  child  is  from  7  to  7^  pounds. 
Both  weight  and  measurement  are  slightly  greater  in  male  than  in  female 
births. 

The  face  and  body  are  plumj).  The  cluld  suckles  and  cries  Instil}'. 
Vernix  caseosa  is  j^resent  chiefly  on  the  child's  back  and  on  the  tlexor 
surfaces  of  the  limbs.  The  skin  lies  in  deep  folds  at  the  flexor  surfaces 
of  tlie  joints.  Portions  of  the  integument,  especially  about  the  shoulders, 
are  thickly  covered  with  lanugo.  In  full-term  children  the  skin  is  whiter 
than  in  those  prematm-ely  born.  The  epidermis  begins  to  be  thrown 
off  on  the  second  day.  The  exfoliation  commences  on  the  abdomen, 
spreads  over  the  body  and  lower  part  of  chest,  and  is  complete  in  about 
two  weeks. 

The  location  of  the  umbilicus  is  above  the  center  of  leug-th  of  the 
child's  body.  If  the  child  has  breathed,  the  thorax  is  arched  and  the 
diaphragm  depressed ;  if  respiration  has  not  taken  place,  or  only  imper- 
fectly, the  chest  is  fiat.  The  iinger-uails  project  l)eyond  the  finger-tips, 
the  toe-nails  to  the  end  of  the  bed  of  the  nail.  The  cartilages  of  the  nose 
and  of  the  ear  are  firm.  The  cranial  bones  are  hard,  the  sutiu'es  and 
the  fontanelles  small. 

Ossification  is  beginning  in  the  upper  epiphysis  of  the  tibia  and  in 
the  cuboid  bone.  The  ossific  nucleus  in  the  lower  end  of  the  fenmr  has 
reached  the  diameter  of  neaily  or  quite  ^  of  an  inch.  Ossification  to 
this  extent  in  the  lower  epiphysis  of  the  femur  may  be  taken  as  conclu- 
sive evidence  of  term-development.  This  bony  nucleus  appears  as  a 
small,  distinctly  marked,  briiiht-red  spot  in  the  white  cartilage.  It  may 
be  much  sniaUer  or  entu-ely  wanting  even  in  term-births.  Hartmaim 
failed  to  find  it  in  12  cases  out  of  102. 

The  examination  t)f  the  epiphysis  for  determining  the  stage  of  ossifi- 
cation should  be  conducted  as  follows :  The  knee  is  slightly  flexed  and 
the  joint  laid  open.  Several  horizontal  sections  are  then  made  through 
the  epiphysis.  The  dimensions  of  the  bony  nucleus  may  thus  be  readily 
determined.  Its  greatest  diameter  at  term,  which  is  the  transverse,  is 
from  2  to  5  mm.  {>(  inch). 

When  only  portions  of  a  dismembered  body  are  at  the  disposal  of  the 
expert,  his  conclusion  must  be  based  on  the  evidence  of  development 
afforded  by  the  bones.  Measui-ements  of  the  bones  are  liable  to  be  mis- 
leading, yet  may  furnish  presumptive  evidence.  The  stage  of  ossification 
is  more  conclusive.  The  femur  and  the  inferior  maxilla,  as  we  have 
already  secMi,  afford  valuable  data. 

Not  only  the  ossific  nuclei  but  the  papilla?  of  the  molars  should  be 
examined.  The  latter  become  crowned  in  the  last  weeks  of  fetal  devel- 
opment.  The  germs  of  the  teeth  do  not  solidify  dui"ing  iutra-uteriue  life. 


482  ^   STSTIJM  OF  LEGAL  MEDIC IXE. 

The  measiiremeut  and  weiglit  of  certain  portions  of  the  body  and  the 
"weight  of  ^dscera  afford  nsefnl  guides  for  determining  the  stage  of  de- 
velopment. The  follo\^^-ng  figures  are  given  on  the  authorit}^  of  Letoiu'- 
neau :  The  distance  from  the  pubis  to  the  top  of  the  head  in  a  new-born 
child  at  term  is  about  12  inches.  The  distance  from  the  pubis  to  the 
internal  condyle  of  the  femiu*  is  2  inches;  fi-om  the  latter  point  to  the 
lower  border  of  the  calcaneum,  4^  inches.  The  distance  from  the  acro- 
mion process  to  the  epicondyle  of  the  humerus  is  3J  inches ;  from  the 
latter  point  to  the  styloid  process  of  the  radius,  2f  inches.  The  Aveight 
of  the  right  lung  is  8  drams  and  15  grains ;  of  the  left,  7  drams.  The 
heart  weighs  3  drams  and  45  grains  ;  the  liver,  22  drams  and  45  grains ; 
the  brain,  5 J  ounces;  the  kidney,  2f  drams. 

The  size  of  the  placenta,  too,  has  an  approximately  constant  relation 
to  the  development  of  the  fetus.  At  term  it  is  from  7  to  8  inches  in 
width,  and  its  average  weight  is  1  pound. 

The  a^-erage  length  of  the  uml")ilical  cord  is  20  inches ;  the  length 
varies,  however,  fi-om  7  to  60  inches. 

While  the  foregoing  may  be  regarded  as  a  fair  statement  of  the  facts 
in  the  great  majority  of  eases,  some  latitude  must  be  allowed  for  varia- 
tions in  individual  instances.  The  weight  and  measurements  of  the  child, 
especially,  are  subject  to  deviations  fi'om  the  above-given  figures  in  a 
certain  proportion  of  cases.  Occasionally  a  child  born  at  full  term  may 
be  considerably  below  the  standard  in  point  of  weight  and  size.  This  is 
generally  true  of  twins.  Phenomenal  instances  have  been  reported  in 
which  the  length  of  the  new-born  child  was  22  and  even  24  inches,  and 
its  weight  23roportionately  excessive.  Even  the  extraordinaiy  weight  of 
25  pounds  at  birth  has  been  recorded.  New-liorn  children,  however,  of 
more  than  10  or  at  most  11  pounds  are  exceedingly  rare.  As  a  rale  each 
succeeding  birth  of  the  same  mother  is  larger  than  the  preceding  births. 
Xotwithstanding  these  occasional  excejDtions  to  the  general  rule  of  size 
and  weight,  the  sum  total  of  the  data  available  in  a  given  case  is  sufficient 
for  a  definite  opinion  with  reference  to  the  stage  of  fetal  development. 


3.    WAS   THE   DECEASED   THE   CHH^D   OF   THE   PEISOXER  ? 

The  medical  e^ddence  bearing  on  this  question  will  depend  on  the 
solution  of  several  other  questions  : 

{a)  Has  the  woman  been  recently  delivered  ? 

(b)  How  long  a  time  has  elapsed  since  delivery? 

(c)  Did  the  child  live  after  birth,  and  if  so,  how  long? 
{(l)  How  long  has  it  been  dead? 

The  facts  relating  to  the  fii'st  and  second  questions  have  been  dis- 
cussed under  Abortion.     The  other  questions  are  considered  below. 


4.    WAS   THE   CHILD   DEAD   OR   XLWE   AT   ITS   BIRTH? 

{^tate  of  the  Lungs. — Piihnonarij  Docimasia. — The  most  valuaT)le  evi- 
dence for  determining  whether  the  child  lived  after  biith  is  afforded  l\v 
the  condition  of  the  lungs.  Before  the  first  respiratory  act  these  organs 
are  devoid  of  air.     As  a  nile  the  child  breathes  for  the  first  time  only 


ABORTION  AND  INFANTICIDE.  483 

after  its  complete  ex])iilsioii  from  the  maternal  passaj^os.  Not  infre- 
quently, however,  resj)iratoi'y  movements  Ix'^in  duT-inji'  the  l)irth.  Wliile 
it  is  g'enerally  possil)k^  to  (letri-miue  l)y  examination  (»f  the  liiu^-s  after 
death  whether  or  not  tlu;  eliild  liad  liivatlicd,  these  or<i';iiis,  uiil'oi-tunately, 
afford  no  evidenee  l)y  which  it  can  l)e  always  learned  whether  the  first 
rcspii-atory  aet  UhAs.  plaee  before  or  after  the  birth  was  complete.  Evi- 
dence that  the  dead  child  had  breathed  is  no  proof  that  it  was  born  alive 
in  the  h^g-al  sense  of  the  term. 

The  lung's  are  fully  expanded  only  after  the  eliild  has  breathed  for 
several  minutes  or  hours.  When  the  air-cells  are  so  com})letely  filled 
that  the  lung's  crc^pitate  under  j^ressure,  it  is  fair  to  presume  that  the 
child  continued  to  breathe  for  some  time  after  it  was  completely  born. 
Especially  is  this  true  of  childi-en  prematurely  born,  since  tlie  alveoli  do 
not  fill  so  prom})tly  in  the  immature  as  in  the  full-term  infant. 

On  opening  the  thorax  of  a  new-born  child  which  has  not  breathed, 
the  lungs  are  found  small,  do  not  appear  to  fill  the  chest,  and  do  not 
€over  the  pericardium.  They  present  a  smooth  surface,  the  color  of 
which  is  most  frecpiently  a  deep  purplish  red.  Since  the  color  changes 
somewhat  after  exposure  to  air,  the  appearance  should  l)e  noted  on  first 
opening  the  chest.  They  have  the  consistency  of  liver,  and  do  not  crepi- 
tate under  the  fingers.  On  incision  they  present  a  compact  structure 
with  no  appearance  of  reticulation. 

The  average  weight  of  the  lungs  before  respiration  is  G49  grains,  in- 
cluding the  bronchi  and  trachea.  The  precaution  must  be  taken  before 
removing:  the  lungs  for  weighing  to  ligate  the  i)ulmonary  vessels  to  pre- 
vent the  escape  of  l)lood.  It  must  not  be  forgotten  that  the  weight  of 
the  lungs  will  differ  according  to  the  size  of  the  child  above  or  below  the 
standard,  and  that  it  does  not  even  bear  an  absolutely  fixed  ratio  to  the 
weight  of  the  body. 

The  si)ecific  gravity  of  the  lungs  before  inflation  is  greater  than  after 
tlie  child  has  breathed.     Placed  in  water  they  promptly  sink. 

After  respiration,  if  the  lungs  have  been  fully  inflated  they  are  much 
increased  in  volume,  they  fill  the  chest,  and  their  anterior  margins  over- 
lie the  greater  part  of  the  heart.  They  assume  a  pinkish  or  bright-red 
color,  have  a  spongy  feel,  aiul  crepitate  on  pressure  with  the  fingers. 
The  surface  is  lolndated,  a.nd  tlui  outlines  of  the  alveoli  are  plainly  vis- 
ible. They  show  a  vesicular  structiu-e  on  incision,  and  a  fi-othy  fluid 
oozes  from  the  cut  surface. 

The  al)solute  weight  is  nearly  doubled  by  the  afflux  of  blood  which 
takes  place  on  the  establishment  of  respiration.  The  specific  gravity,  on 
the  other  hand,  is  greatly  diminished  in  consequence  of  the  access  of  air 
to  the  alveoli. 

All  the  foregoing  changes  are  imperfectly  developed  in  i)roportiou  as 
the  lungs  are  only  partially  expanded.  It  is  especially  imjiortant  to  note 
that  when  the  child  Inis  breathed  imperfectly  the  dilated  portions  are 
raised  above  the  general  surface  of  the  lungs,  and  have  taken  on  the 
bright  vermilion  color  characteristic  of  respiration,  while  the  uncxpanded 
l)ortions  still  retain  the  livid  hue  of  the  fetal  state. 

The  Hydrostatic  Test.— The  specific  gravity  of  the  lungs  before  res- 
piration is  1.05.  These  organs  in  the  fetal  condition  accordingly  sink 
when  placed  in  water.  After  full  inflation  they  float  with  considerable 
buoyancy.     The  pulmonary  tissue,  while  actually  heavier  after  the  child 


484  ^  SYSTi:2r  of  legal  medlcixe. 

has  breatlied  tliau  before,  owing  to  the  af0.nx  of  blood  to  its  vessels  on 
the  establishment  of  respii-ation,  is  relatively  lighter  than  the  correspond- 
ing bn1k  of  water,  o\\'ing'  to  the  increase  in  volnme  consequent  nj^on  the 
distention  of  the  alveoh  with  ah-. 

To  decide  the  question,  then,  whether  the  lungs  have  been  inflated^ 
they  are  removed  from  the  chest,  the  large  bronchi  and  trachea  being- 
included,  and  placed  hi  water  which  must  be  approximately  pure  and  at 
even  temperatm-e  with  the  smTOunding  au-.  Should  they  float,  they 
should  be  cut  apai-t  and  each  tried  by  itself.  Each  lung  shoid.d  then  be 
cut  into  ten  or  twenty  pieces,  and  the  sections  tested  separately.  If  all 
float,  the  lungs  have  both  been  completely  expanded  with  air.  Should 
both  lungs,  one  lung,  or  any  of  the  pieces  sink,  it  is  generally  to  be  as- 
simied  that  these  organs  have  remained  wholly  or  partially  in  the  fetal 
condition.  As  a  rule,  then,  flotation  of  the  lungs  or  any  portion  of  them 
may  be  taken  as  evidence  that  the  child  had  breatlied,  and,  conversely,, 
failure  to  float  is  to  be  regarded  as  proof  that  respiration  had  not  taken, 
place.     To  these  rules,  however,  there  are  certain  exceptions : 

{a)  Artificial  Insufflation. — The  lungs  may  have  been  artificially  in- 
flated, either  in  the  legitimate  endeavor  to  resuscitate  the  chdd,  or  with 
intent  to  conceal  the  fact  that  it  had  been  willfully  destroyed.  Merkel, 
experimenting  on  the  eifeet  of  artificial  resi:)u-ation,  found  that  after 
tliu-ty  Schultze  swings  the  lungs  of  a  still-born  infant  were  well  expanded. 
After  fifteen  swings  they  were  only  partially  inflated.  Shuple  movements 
of  the  dead  child — shaking,  tossing,  compression  or  expansion  of  the  chest,, 
or  a  few  feeble  Schultze  swings — produced  no  expansion  of  air-cells. 

When  the  lungs  have  been  found  expanded,  the  medical  expert  will  be 
called  upon  to  show  whether  the  expansion  was  the  result  of  respiration 
or  of  artificial  insufflation.  TVliile  in  either  case  they  will  float,  the  abso- 
lute weight  will  not  have  been  augmented  by  insufflation  after  death,  as- 
is  the  case  when  the  child  has  breathed,  for  the  obvious  reason  that  in 
post-mortem  inflation  no  afflux  of  blood  to  the  lungs  takes  place.  The 
weight  remains  as  in  the  fetal  state.  For  the  same  reason,  lungs  which 
have  been  artificiaUy  inflated  after  death  do  not  accxuu-e  the  pink  color 
characteristic  of  respu-ation,  but  are  pale  and  colorless.  Moreover,  blood 
cannot  be  pressed  from  the  pulmonary  structui-e  on  incision,  as  can  be 
done  in  the  case  of  the  lung  that  has  breathed.  Again,  it  is  in  general 
highly  improbable  that  artificial  respiration  would  be  practiced  except 
by  the  physician  for  the  piu'pose  of  resuscitation. 

(&)  Futref action. — In  rare  instances  the  lungs  from  the  body  of  a  child 
that  has  not  breathed  may  float,  owing  to  the  presence  of  putrefactive 
gases  in  the  pulmonary  tissues.  In  such  cases  the  marks  of  decomposi- 
tion wiU  be  found  in  other  portions  of  the  body.  Putrefactive  changes 
take  place,  in  fact,  more  rapidly  in  most  other  structures  than  in  the 
hmgs.  Again,  the  gases  of  putrefaction  occupy  the  intercellular  portions 
of  the  pulmonary  organs,  and  can  be  in  a  great  measiu-e  expelled  from 
sections  of  the  lung  by  pressure  between  the  fingers,  while  the  expansion 
of  the  aii--ceUs  remains  nearly  or  quite  unchanged  under  pressure.  The 
sm-face  is  studded  with  bnlhp,  the  structure  softened  and  presenting  the 
greenish  or  brownish  discoloration  and  ofl'ensive  odor  of  putrefaction. 
When  the  putrefactive  process  has  not  gone  too  far.  the  mere  puncture 
of  the  gaseous  vesicles  may  permit  the  lung  or  its  segments  to  sink  in 
water.     It  is  important  to  distinguish  between  putrefaction  and  macera- 


ABOUTIOX  AM)    IMWyTICIDE.  4tS5 

lion  ill  eximiiiiiiig"  the  cadaver  of  a  new-born  infant.  Maceration  occurs 
in  the  body  of  a  fetus  which  has  been  cari'ied  in  utero  for  some  days 
after  death  witii  the  fetal  nienibranes  iin))roken.  In  this  condition  the 
body  is  shriveled  and  the  cranial  vault  collapsed,  l)ut  the  destruction  of 
tissue  aiul  the  characteristic  odoi-  of  j)utrel'a('tion  are  absent. 

{(')  Solidijirntioii. — On  the  other  hand,  under  certain  circumstances 
the  hydrostatic  test  may  fail  to  establish  the  fact  even  when  i'es])ira- 
tion  has  taken  place.  C'onsolidation  of  the  air-cells  may  occur  frojii 
disease.  This  happens  in  pneumonia  and  in  edema  of  the  lungs.  A 
little  cai-e  on  the  part  of  the  examiner  will  readily  eliminate  this  source 
of  error. 

{(I)  Afeh'cfdsis. — Ceases  have  been  i-ecorded,  too,  in  Avhich,  though  the 
child  lived  several  hours  and  even  days,  eveiy  portion  of  the  lungs  sank 
when  })laced  in  water  after  deafh.  Eckervogt  has  reported  a  case  iu 
which  ai  child  cried  out  loudly  after  birth,  then  stopped,  l)ut  lived  twenty- 
three  lioui's ;  yet  after  death  no  air  was  found  iu  the  lungs  and  every 
portion  of  them  sank  in  water.  Bernt  met  with  a  case  in  which  a  seven 
months'  child  died  two  hours  after  bii'tli ;  the  lungs  were  divided,  and 
every  segment  sank  in  water.  Remer  relates  an  instance  in  which  the 
entire  lungs  sank  after  the  child  had  lived  four  days.  Many  other  similar 
instances  have  been  observed.  They  are  to  be  explained  on  the  assump- 
tion of  a  partial  atelectasis,  the  air-cells  having  received  enough  air  to 
maintain  life  for  a  short  period,  yet  not  enough  to  cause  flotation  of  the 
puhuona-iy  structures.  It  is  possible  that  partial  resorption  of  the  re- 
sidual air  takes  place,  as  claimed  by  Eckervogt. 

{e)  Freezing. — The  precaution  must  be  taken  to  observe  that  the  lungs 
are  not  frozen  before  a.pi3lying  the  hydrostatic  test,  since  frozen  pubno- 
nary  tissue  nuiy  float,  even  Avhen  in  the  fetal  state,  owing  to  the  presence 
of  ice.  The  frozen  organs  should  be  immersed  in  warm  water  until  they 
have  completely  thawed. 

Pulmonary  Docimasia  by  the  Microscope. — This  method  of  exam- 
ining the  state  of  the  lungs  in  suspected  infanticide  was  proposed  by 
Bouchut.  Under  a  magnifying  power  of  five  or  ten  diameters  the  cut 
surface  of  a  lung  which  has  not  breathed  presents  the  appearance  of 
solid  tissue.  It  sIioavs  reticulation,  but  no  air-vesicles.  On  the  other 
hand,  the  pidmonary  structure,  after  respiration  has  taken  place,  exhibits 
under  the  nuignifier  agglomerations  of  air-cells.  By  its  aid  imperfect 
expansion  of  pulmonary  lol)ules  is  readily  recognized.  If  respiration 
has  not  been  fully  established  a  portion  of  the  alveoli  is  seen  to  be 
undilated.  Tlie  inflated  air-vesicles  do  not  disappear  under  pressure 
with  the  fingers,  as  do  the  gaseous  bubbles  in  the  intercellular  tissues. 

Moreno  proposes  that  the  smallest  bronchioles  be  examined.  The  cili- 
ated epithelium  passes  into  cubical,  and  by  expansion  of  the  alveoli  iu 
inspiration  becomes  squamous.  The  method  is  scarcely  practicable  for 
general  use,  since  only  after  examining  the  entire  lung  could  partial 
expansion  be  excluded. 

Has  the  Child  Cried? — The  only  medical  evidence  on  this  ([uestioii 
is  to  be  sought  in  the  condition  of  the  lungs.  Full  inflation  of  the  air- 
cells  may  generally  be  taken  as  proof  that  the  child  has  cried.  On  llu^ 
other  hand,  it  is  improbable  that  it  had  uttered  any  sound  if  the  lungs 
are  found  in  the  fetal  state.  Imperfect  dilatation  of  the  puluKniary  lob- 
ides  is  not  inconsistent  with  the  allegation  that  the  child  cried  feebly. 


48G  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

The  fact  that  it  had  done  so,  however,  is  not  evidence  of  lining  bu'th, 
since  the  child  may  cry  before  it  is  complete!}'  born. 

The  possibihty  of  an  intra-nterine  cry  (vagitus  iderinus)  is  'well  recog- 
nized. This  can  occm-,  obviously,  only  after  the  rupture  of  the  mem- 
branes, and  with  such  accident  or  manipulation  as  may  admit  air  into  the 
utero- vaginal  tract.     The  child  cannot  avy  without  air. 

In  general  it  must  be  remembered  that  the  presence  of  air  in  the 
lungs,  however  demonstrated,  while  it  is  usually  to  be  taken  as  proof  of 
life  during  bu'th,  is  not  e^-idence  of  living  birth.  The  lungs  may  be 
partially  inflated  in  a  child  that  had  died  before  it  was  completel}'  born. 

Air  in  the  Alimentary  Canal. — Before  birth  no  air  is  contained  in  the 
stomach  or  intestines.  Au'  gains  access  to  the  stomach  and  the  deeper 
portions  of  the  digestive  tract  dii-ectly  after  birth  in  the  hving  child. 
This  occurs  either  by  aspiration  or  by  the  act  of  swallowing.  Its  pres- 
ence, therefore,  as  indicated  by  flotation  of  these  organs  when  placed  in 
water,  is  generally  an  indication  that  the  child  was  born  alive,  and  the 
inference  is  the  stronger  in  proi)ortion  as  the  air  is  found  in  larger 
quantities  and  at  a  lower  point  in  the  bowel. 

To  apply  this  test  the  stomach  must  be  ligated  at  each  end  before  it 
is  opened,  and  the  section  of  intestine  must  be  tied  in  like  manner  on 
opening  the  abdomen.  It  must  not  be  forgotten,  however,  that  aii*  may 
be  introduced  into  the  stomach  and  intestinal  canal  dui'ing  attemiDts  at 
insufflation  of  the  lungs,  and  that  the  gases  in  the  stomach  and  bowels 
may  be  the  product  of  putrefactive  decomposition. 

Merkel  found  air  in  the  digestive  tract  of  the  new-born  child  only 
after  thii't^'  Schultze  swings,  never  after  other  methods  of  insufflation. 
The  mouth-to-mouth  method  he  j)robably  did  not  use. 

Cardiac  Movements. — As  has  been  already  stated,  life  terminates 
with  the  cessation  of  the  heart-beats.  If  on  auscultation  over  the  chest 
the  heart-sounds  are  heard  after  bii'th,  or  if  cardiac  mo^-ements  can  be 
felt  by  pressmg  the  fingers  up  under  the  inferior  costal  iDorder  on  the 
left  side,  or  if  the  uml)ilical  stum23  pulsates,  the  child  is  lining,  even  in 
the  absence  of  respiration. 

Wreden's  Test. — Wreden  has  caUed  attention  to  the  fact  that  at  birth 
the  middle  ear  is  filled  mth  epithelial  cells  and  mucus,  and  that  in  the 
li-^ing  child  these  substances  are  absorbed  within  a  short  time  after  birth. 
The  presence  of  a  ea^dty  in  the  middle  ear  is  therefore  to  be  taken  as 
e\ddence  that  the  child  had  sur^dved  its  l;)ii'th. 

Docimasia  of  the  Circulation. — Coagidability  is  the  property  of 
living  blood.  The  blood  does  not  coagulate  in  the  dead  body.  Hence 
ecchjTuoses  or  blood-coagula  in  the  tissues  of  the  body  are  proof  that  the 
child  was  lining  at  the  time  the  injury  was  inflicted,  ii-respective  of  the 
state  of  the  lungs. 

How  Long  did  the  Child  Live  ? — It  is  not  always  possible  to  deter- 
mine the  length  of  time  the  child  lived.  The  question,  as  a  rule,  can  be 
only  approximately  decided.  The  facts  which  bear  on  its  solution  are  the 
following:  The  skin  sheds  its  superficial  epithehum  in  the  fii'st  day  or 
two  after  birth,  and  remains  red  for  a  week  or  two.  After  this  length  of 
time  it  assumes  a  whiter  appearance.  The  caput  succedaneum  subsides 
within  from  twenty-four  to  forty-eight  hours  after  birth.  Its  persistence 
after  death  may  Ije  regarded  as  e"\'idence  that  the  child  did  not  survive  the 
biiiih  for  more  than  a  few  hours  at  the  most.     A  blood-tumor  (cephal- 


ABoirnux  JXD  infanticide.  487 

lia^inatoma)  must  not  be  mistaken,  however,  for  the  mere  edematous  swell- 
iuji,'  of  the  caput  sueeedaueum.  These  bloody  elfusi(ms  usually  persist  for 
two  or  there  uu)uths. 

The  umljilical  stump,  when  exposed  to  the  air,  or  if  loosely  covered 
with  a  dr}'  dressing,  remains  in  a  fresh  state  for  only  a  short  time,  be- 
coming dark-colored  and  shriveled  by  the  second  day.  In  the  course  of 
two  or  three  days  more  it  assumes  a  horny  consistency,  and  generally  falls 
oif  by  the  end  of  the  tif  th  day.  Yet  in  exceptioiuil  instances  the  cord  may 
not  separate  for  a  week  or  more.  It  must  be  l)orne  in  mind  that  changes 
simulating  those  which  occur  in  the  li^dng  infant  may  take  place  after 
death,  and  that  the  separation  of  the  cord  may  occur  from  putrefactive 
causes  after  the  child  is  dead.  The  wound  which  it  leaves  in  the  living 
child  usually  heals  in  the  course  of  four  or  five  days  after  the  cord  sepa- 
rates, yet  complete  cicatrization  may  be  delayed  for  a  variable  period. 

Obliteration  of  the  umbilical  vessels  is  complete  in  from  six  to  seven 
days  after  birth.  The  umbilical  arteries  are  closed  within  two  days ;  the 
umbilical  vein,  ductus  veuosus,  and  the  foramen  ovale  in  the  course  of  six 
or  seven  days.  Yet  these  periods  are  subject  to  some  variation,  and  it 
is  not  an  uncommon  experience  in  post-mortem  examinations  to  find  the 
foramen  ovale  persistent  in  the  adult.  The  ductus  arteriosus  is  obliter- 
ated in  from  ten  to  fifteen  days. 

The  examination  of  the  lungs  will  show  whether  respii*ation  has  been 
established.  If  the  lungs  are  found  in  the  fetal  state  the  child  has  died 
either  before  or  dii*ectly  after  the  bii'th.  Yet  a  condition  of  partial  ate- 
lectasis, as  has  been  seen,  is  not  inconsistent  with  life  for  a  few  hoiu's  or 
even  days. 

A  frothy  coudition  of  the  fluid  contained  in  the  stomach  is  evi- 
dence that  the  child  lireathed  and  continued  to  live  for  at  least  several 
minutes — long  enough  to  have  swallowed  fluid  material  which  had  been 
mixed  with  air  in  the  mouth.  The  presence  in  the  stomach  of  lanugo  and 
particles  of  vernix  caseosa  from  swallowed  liquor  amnii  would  indicate 
that  the  child  had  probably  died  within  two  or  three  days  after  birth, 
before  these  substances  could  be  passed  off.  This  conclusion  would  be 
borne  out  by  the  presence  of  meconium  in  the  intestinal  tract.  On  the 
other  hand,  if  the  stomach  contains  food  and  the  meconium  has  been 
wholly  evacuated  from  the  liowels  nnd  replaced  by  feculent  material,  the 
child  has  lived  for  at  least  three  or  four  days. 

Among  the  substances  that  should  be  looked  for  in  the  stomach  are 
milk,  blood,  sugar,  and  starchy  material.  Milk  and  blood  can  usually  be 
identified  by  the  microscope.  The  iodine  test  should  be  used  for  stai-ch ; 
Fehling's  or  the  fei'mentation  test  for  the  sugar  of  milk  or  gTape-sugar. 
If  the  precaution  be  taken  to  boil  a  portion  of  the  stomach  contents  be- 
fore testing,  with  dilute  hydrochloric  acid,  any  cane-sugar  that  may  be 
present  will  be  convei'ted  into  grape-sugar. 

Attention  has  lieen  called  to  the  bony  nucleus  in  the  lower  epiphysis 
of  the  femur,  as  proof  of  full-term  development.  Growth  of  this  ossific 
center  bej^ond  the  maximum  size  at  term  would  indicate  that  the  child  had 
lived  for  at  least  several  days.  The  extent  of  ossific  development  in  other 
bones  should  also  be  noted. 

How  Long  has  the  Child  been  Dead  ? — The  decision  of  this  question 
is  more  difficult  the  longer  the  tinu^  that  has  elapsed  after  death.  An 
.approximate  estimate  is  generally  possible  when  the  examination  is  held 


488  -^   SYSTEM  OF  LEGAL  MEDICINE. 

within  a  week  or  little  more  post-mortem.  The  only  medical  evidence  is 
afforded  by  the  stage  of  decomposition.  The  rapidity  of  the  pntrefactive 
changes,  however,  will  obviously  depend  on  the  temperatiu-e  and  humidity 
of  the  ail"  and  other  physical  conditions  to  which  the  body  has  been  ex- 
posed. They  go  on  more  rapidly  in  the  air  than  in  other  media.  As  has 
iDeen  alreadj^  stated,  post-mortem  changes  begin  at  a  later  period  in  the 
lungs  than  in  most  other  structures  of  the  body.  Marked  putrefaction  iu 
these  organs  is  therefore  proof  that  the  body  has  been  dead  for  a  consid- 
erable length  of  time. 

5.    WHAT   WAS   THE   CAUSE   OF   THE   CHELD'S   DEATH? 

The  essential  question  to  be  decided  by  the  medical  e\'idence  in  a  case 
of  alleged  infanticide  is  the  cause  of  death.  Nearly  twenty  percent, 
of  all  children  die  before  or  shortly  after  bii-th  from  other  causes  than 
criminal  violence.  In  prematiu'e  bii-ths  the  death-rate  is  still  greater,  and 
is  larger  in  proportion  to  the  degree  of  prematurity.  Male  ehildi'en  are 
more  Hable  to  die  during  labor  than  female,  OT\dng  to  the  somewhat  larger 
size  of  the  former  and  the  gTeater  difficulty  of  bii-th.  So,  too,  children 
die  in  larger  numbers  in  fii-st  than  in  subsequent  labors  of  the  mother, 
the  proportion  being  one  to  eleven  in  the  former  and  one  to  thu'ty-one 
in  the  latter.  These  facts  must  be  taken  into  aecoimt  in  estimating  the 
probability  of  death  from  natural  causes.  It  is  therefore  necessary  that 
the  medical  witness  be  familiar  with  the  natui-al  causes  of  death  in  the 
new-born. 

NATURAL   CAUSES   OF   DEATH   Es'   XEW-BORX   CHILDREN. 

The  fetus  may  die  in  utero  or  shortly  after  bii'th  in  consequence  of 
malformations,  asphyxia,  operative  or  accidental  ^dolence,  or  from  fetal 
or  maternal  disease. 

Malformation. — Congenital  defects  are  frequently  met  with.  They 
may  be  found  in  any  organ  of  the  body  and  they  seldom  occui-  singly. 
Death  from  this  cause  takes  place  oftener  after  than  before  bii'th.  Among 
the  faults  of  development  which  are  inconsistent  with  extra-uterine  life 
are  anencephalus,  exencephalus,  spina  l)ifida  with  ulceration  of  the  tumor, 
acardia,  and  certain  other  malformations  of  the  heart.  The  heart  may 
consist  of  but  one  auricle  and  one  ventricle.  The  aorta  and  pulmonary 
artery  are,  in  rare  instances,  transposed,  the  former  coming  from  the  right, 
the  latter  from  the  left  ventricle.  Atresia  of  the  esophagus,  imperforate 
rectum  incapable  of  surgical  relief,  and  marked  ectopia  of  the  abdominal 
or  thoracic  viscera  are  necessarih'  fatal.  Under  this  head,  too,  are  in- 
cluded malformations  of  the  respiratory  tract,  which  prevent  free  access 
of  air  to  the  alveoli  of  the  lungs.  Contraction  of  the  conus  arteriosus,  and 
other  malformations  of  the  heart  or  large  vessels  which  permit  mixing  of 
the  venous  mth  the  arterial  Ijlood,  are  usually  inconsistent  with  extra- 
uterine life  for  more  than  a  limited  period  at  most. 

On  the  other  hand,  moderate  microcephalus  or  hydrocephalus,  spina 
bifida  when  not  ulcerated,  dislocation  of  the  heart,  vah^ilar  cardiac  dis- 
ease, persistence  of  the  foramen  ovale,  transi^osition  of  the  stomach  or  other 
viscera,  exstrophy  of  the  bladder,  and  intra-uterine  amputation  of  limbs,  do 


AiionrioN  A  SI)  ixFAyririDK.  4S9 

not  usually  cause  death.  In  occasional  instances  the  subjects  of  moderate 
hydrocephalus  Uve  to  an  advanced  age.  Spina  bifida  is  much  more  fatal 
when  situated  in  the  cervical  region  than  in  the  lower  portion  of  the  spine. 
Monsters,  in  a  large  proportion  of  cases,  die  soon  after  birth. 

Fetal  Disease. — Congenital  disease  is  an  infrequent  cause  of  death 
in  the  new-born.  Among  the  diseases  which  are  possible  during  intra- 
uterine life  are  cardiac  affections,  rheunuitisni,  rickets,  lenceniia,  general 
dropsy,  scirrhus,  and  probably  all  infectious  diseases.  Examples  of  the 
latter  which  are  known  to  occur  in  the  fetus  are  syphilis,  scarlet  fever, 
measles,  smallpox,  cholera,  typhoid  fever,  yellow  fever,  pneumcmia,  tu- 
berculosis, erysipelas,  and  septicaemia.  Other  causes  of  death  in  the  child 
are,  metallic  impregnation,  parents  too  young  or  too  old,  the  effects  of 
alcoholism  and  certain  other  chronic  diseases  in  one  or  Ijoth  parents, 
nepliritis,  dial)etes,  and  feeble  fetal  development. 

Syphilis  is  res})onsil>le  for  more  deaths  in  utero  or  soon  after  birth  than 
iiny  other  fetal  malad}'.  It  may  be  either  of  nniternal  or  of  jjaternal  or- 
igin. When  the  mother  is  sypliihtic  every  ovum  cast  off  from  the  ovary 
is  probaljly  affected  with  the  disease,  and  the  child  which  is  developed 
from  such  an  ovum  is  syphilitic.  If  the  father  be  syphilitic  it  is  believed 
by  many  authorities  that  tlie  spermatozoa  contain  the  active  cause  of  the 
disease  and  convey  syphilis  to  the  ova  which  they  impregnate.  When  the 
mother  is  infected  at  the  time  of  the  fruitful  coitus,  or  shortly  before, 
the  child  is  invariably  syphilitic.  Frequently,  thougii  not  uniforndy,  it 
develops  the  disease  when  the  maternal  infection  is  contracted  during  the 
pregnancy.  In  something  less  than  fifty  percent,  of  syphilitic  cases  the 
pregnancy  terminates  in  abortion.  A  large  proportion  of  the  children 
die  in  utero  in  the  later  months  of  gestation.  Only  a  small  percentage  of 
those  born  alive  long  survive  the  birth. 

In  children  born  dead  from  this  cause,  the  recognition  of  the  disease 
is  usually  not  difficult.  Among  the  most  conspicuous  lesions  of  fetal  sj-pli- 
ilis  are  osteochondritis  l)etween  the  head  and  shaft  of  the  femur  and 
other  long  bones,  and  enlargement  of  the  liver  and  spleen.  On  examining 
the  cartilage  which  separates  the  diaphysis  from  epiphysis  in  the  long 
bones  and  especially  at  the  lower  end  of  the  femur,  the  line  between  bone 
and  cartilage,  instead  of  being  narrow,  clean-cut,  and  shaii^ly  defined,  as 
in  health,  is  found  wide  and  irregular  in  shape  and  of  a  yellowish  color. 
The  liver  is  enlarged  to  one  twelfth,  frequently  to  one  eighth,  the  body 
weight. 

Asphyxia. — One  of  the  commonest  causes  of  still-birth  is  asphyxia 
resulting  from  prenuiture  attempts  at  pulmonary  respiration.  It  is  to  be 
remembered  that  during  intra-uterine  life  the  respiratory  function  is  per- 
formed by  the  placenta,  after  l)irth  by  the  lungs.  So  long  as  the  placental 
functions  are  perfectly  performed,  the  child  has  no  need  of  pulmonaiy 
respiration,  and  makes'no  effort  to  breathe.  If  the  placental  functions  are 
wholly  or  partially  susp(mded,  respiratory  nu)vements  are  provoked  by 
the  air-hunger  thus  developed.  This  may  occur  before  l)irth  from  com- 
pression of  the  und)ilical  cord,  ])remature  detachment  of  the  placenta, 
partial  or  complete,  ])rofuse  heuK^rrhage,  and  from  undue  compression  of 
the  placenta  by  violent  and  persistent  uterine  contractions. 

If  the  first"^  attempts  at  respiration  take  place  in  the  absence  of  air 
while  the  head  is  still  in  the  birth  canal,  usually  liquor  amnii,  blood, 
vaginal  mucus,  or  meconium  is  drawn  into  the  trachea  and  bronchi. 


490  ^   SYSTEM  OF  LEGAL  MEDLCIXE. 

Access  of  ail-  to  the  alveoli  and  the  lungs  may  thus  be  prevented  after' 
bii'th. 

The  essential  element  in  the  asphyctic  condition  is  the  venous  stasis- 
superinduced  in  the  thoracic  cii'culation  \>j  prematiu-e  respii'ator}^  efforts. 
On  expansion  of  the  thorax  in  the  fii'st  respiratory  movements  the  capil- 
laries of  the  lungs  are  filled  hj  force  of  aspii'ation.  In  the  absence  of  aii-, 
blood  stasis  is  developed  and  congestion  of  the  entu-e  mtrathoracic  venous- 
circulation.  A  secondary  venous  congestion  is  frequently  developed  in 
the  general  cii'culation. 

Prolonged  compression  of  the  brain  during  spontaneous  labor  in 
narrow  pelvis,  or  liy  the  forceps  in  artificial  extraction,  may  retard  and 
arrest  the  action  of  the  fetal  heart  in  the  absence  of  attempts  at  respi- 
ration through  irritation  of  the  pneiuuogastric  nerve.  For  a  full  expo- 
sition of  the  pathology  of  asj)hyxia  neonatorum  the  reader  is  referred  to- 
Lusk's  Science  and  Art  of  Midicifenj.  The  appearances  found  after  death 
by  asphj^ia  are  described  under  Infanticide  by  Suffocation. 

Accidents  and  Injuries. — The  new-born  child  may  die  from  accidental 
injui-ies  sustained  at  the  time  of  birth  or  soon  after.  Cases  are  frequently 
reported  in  which  owing  to  unexpected  dehvery  the  child  has  fallen  upon 
the  floor  or  has  been  expelled  into  a  water-closet. 

Injuries  sustained  by  falls  OAving  to  sudden  expulsion  of  the  child  in 
dangerous  places,  as  has  been  ah-eady  stated,  are  not  often  severe  enough 
to  be  fatal.  Precipitation  into  a  privy  vault  exposes  the  child  not  only  to 
mechanical  injimes  but  to  the  dangers  of  drowning,  or  of  suffocation  by 
noxious  gases.  In  laceration  of  the  umbilical  cord  death  may  take  place 
from  hemorrhage.  Bouehut  cites  a  case  in  which  a  stout  cord  had  parted 
during  dehvery  by  forceps  and  the  child  had  bled  to  death  before  biith. 
Yet  the  division  of  the  cord  without  ligature  is  by  no  means  necessarily 
followed  by  much  bleeding.  The  funic  stump  is  less  likely  to  bleed  when 
torn  than  when  cut. 

Umliihcal  or  other  hemorrhages  may  occiu*  with  a  fatal  result  from 
other  causes  than  non-ligation  of  the  cord.  Even  when  the  funis  is 
securely  ligated,  persistent  and  uncontrollable  hemorrhage  may  take  place 
from  the  umbilicus  and  from  other  regions  of  the  body,  owing  to  hem- 
ophiHa  or  other  causes. 

In  hemorrhage  due  to  placenta  pr^evia,  or  prematui'e  separation  of  a 
normally  placed  placenta,  the  child  is  frequently  born  dead  or  in  a  non- 
viable condition  from  asphyxia.  In  difficult  breech  extraction  fatal  injm-y 
may  be  done  to  the  cervical  j^ortion  of  the  spinal  cord.  In  instrumental 
labors  the  fetal  mortality  is  increased.  Intracranial  injuries  may  arise 
from  compression  of  the  head  in  difficult  spontaneous  births,  especially  in 
narrow  pelves. 

In  delivery  in  the  absence  of  the  physician  the  child  is  sometimes  suf- 
focated from  lying  with  its  face  in  a  pool  of  blood  and  liquor  amnii.  In 
very  rai-e  instances  the  child  is  born  mth  the  membranes  unbroken. 
This  occurrence  is  much  less  frequent  at  term  than  in  ^^remature  de- 
livery. Though  alive  at  birth,  T\athout  interference  the  child  dies  by  suf- 
focation. The  chest  expands  in  the  effort  to  breathe,  but  no  air  can 
enter  the  lungs.  Deaths  of  new-born  children  from  overlying  are  occa- 
sionally reported,  the  mother  rolling  over  unconsciousl}'  upon  the  child 
in  her  sleep. 

It  is  the  duty,  therefore,  of  the  medical  jurist  in  passing  upon  a  case 


ABOnriOX  AM)    IXFJXTICIDE.  4<Jl 

of  alleged  eliild-miirder  to  examine  the  eliild  for  marks  of  \aolence  at- 
tributable to  the  birth,  and  for  other  aceideutal  eauses  of  death,  as  Avell 
as  for  the  evidence  of  eriiiie. 

Maternal  Disease. — Many  aente  diseases  of  the  mother  are  liable  to 
result  in  the  death  and  i)remature  exyidsion  of  the  fetus.  The  child  may 
die  by  the  direct  influence  of  the  disease  poison,  by  the  effects  of  the  dis- 
ease upon  the  maternal  pelvic;  cireidation,  or  from  excessively  high  tem- 
perature. In  ease  of  the  death  of  the  mother  during-  gestation  the  child 
dies  in  iitero.  In  protracted  sickness  the  death  of  the  fetus  usually  pre- 
cedes that  of  the  mother.  When  the  mother  dies  suddenly,  the  child  gen- 
erally survives  her  l)y  a  period  seldom  exceeding  five  or  six  minutes. 

It  is  the  duty  of  the  physician  when  present  at  the  death  of  the  mother 
during  pregnancy  to  immediately  extract  the  child  if  it  gives  evidence  of 
being  ali  ve  and  viable.  Post-mortem  delivery  may  l)e  rapidly  accompIi.shed 
by  deep  cervical  incisions  and  extraction  with  the  forceps  or  by  the  feet. 
A  post-mortem  Cfesarean  section,  however,  if  the  consent  of  the  friends 
can  be  had,  is  the  preferal^le  method.  Delivery  by  abdominal  incision  is 
more  rapid  than  is  ordinarily  possible  by  the  natural  passages,  and  the 
child  is  less  exposed  to  injury.  The  operation  must  generally  be  done 
within  six  minutes  after  tlie  death  of  the  mother;  yet  cases  have  l.)eeu  re- 
ported in  which  the  child  lived  four  or  five  hours  after  the  mother's  death, 
and  living  deliveries  have  been  accomplished  after  an  interval  of  thii'ty 
minutes. 

Pathological  conditions  of  the  placenta  liable  to  result  in  the  death  of 
the  fetus  by  interruption  of  its  nutrition  are  degeneration  of  the  chorial 
villi,  apoplexy,  thrombosis,  and  retro-placental  hemorrhage.  Exception- 
ally, hydi*aumios  is  attended  with  intra-uteriue  death  of  the  child. 


CREVnNAL  CAUSES   OF   DEATH. 

Infanticide  by  Suffocation. — A  common  method  of  infanticide  is  by 
suffocation.  A  handkercliief  or  cloth  may  be  thrust  into  the  mouth 
either  before  or  after  the  establishment  of  respiration,  or  the  nose  and 
mouth  may  be  foreildy  held  till  death  ensues.  Cotton,  feathers,  and 
other  similar  nuiterials,  and  even  liquid  substances,  have  been  used  for 
the  pui-pose  of  obstructing  the  respiratory  passages.  The  child  may  be 
smothered  by  covering  it  closely  under  the  bedclothes.  The  vapors  of 
chloroform,  illuminating  gas,  and  other  poisonous  gases  have  been  ad- 
ministered by  iidialation  with  criminal  intent. 

The  post-mortem  ai^pearances  after  fatal  suffocation  are  the  same  in 
the  new-born  as  in  adults.  The  skin  is  of  a  general  livid  color  and  studded 
with  ecchymotie  patches,  the  face  is  swollen,  and  the  superficial  veins 
turgid.  The  conjunctiva^  are  injected  and  the  eyeballs  protruding,  yet 
the  fullness  of  the  superficial  blood-vessels  subsides  in  great  measure 
within  a  few  hours  after  death. 

If  the  child  had  breathed,  blood  and  frothy  mucus  exude  from  the 
mouth  and  nostrils. 

p]ccliymoses  and  imprints  of  the  fingers  or  nails  on  the  nose  and 
mouth  may  he  present.  The  presence  of  poisonous  gases  in  the  respi- 
ratoiw  tract  is  usuallv  betraved  bv  their  odor. 


492  -^   SYSTEM   OF  LEGAL  MEDLCIXE. 

In  fatal  asphyxia  by  smothering  nnder  the  bedclothing  it  is  rare  to 
find  other  than  internal  lesions. 

Foreign  bodies  should  be  looked  for  in  the  aii'-passages.  The  blood  is 
generally  fluid.     The  principal  viscera  are  more  or  less  liyperaemic. 

The  lungs  usually  present  the  marks  of  blood  stasis.  A  fairly  constant 
condition  is  the  presence  of  small  subpleural  hemorrhages.  They  maj'  be 
few  in  numljer  or  may  be  thickly  diffused  over  the  surface  of  the  lungs. 
They  occur  most  frequently  at  the  root  and  lower  border  of  the  lungs. 
(Plate  VI.,  Fig.  A.)  Similar  hemorrhages  are  found  in  the  thymus  gland, 
the  pericardium,  endocardium,  and  in  the  pericranial  cellular  structure. 
Yet  subpleural  ecchymoses  are  of  common*  occurrence  in  death  from 
other  causes  than  suffocation.  They  are  significant  of  death  by  ^dolence 
only  when  the  child  has  breathed,  since  they  are  sometimes  found  when 
the  lungs  are  still  in  the  fetal  state.  They  occur  in  death  dui-ing  birth, 
from  compression  of  the  umbihcal  cord.  They  are  to  be  attributed  to 
efforts  made  to  breathe.  They  are  of  value  as  indicating  the  mode  of 
death  only  ^vhen  taken  in  connection  with  other  post-mortem  findings. 

The  ecchymotic  spots  of  suif ocation  must  be  distinguished  from  those 
of  cholera,  purpura,  and  grave  forms  of  eruptive  fevers.  In  the  former 
the  ecchymoses  present  a  dotted  api:)earance,  and  the  spots  are  rounded, 
clear-cut,  and  distinctly  circumscribed.  In  the  latter  they  are  iiTcgular 
effusions  of  a  purplish  color,  and  are  associated  with  the  characteristic 
lesions  of  the  disease. 

In  poisoning  by  phosphorus,  strychnine,  or  prussic  acid,  ecchymoses 
are  found  resembling  those  last  described,  and  the  presence  of  the  toxic 
substance  is  revealed  by  chemical  analyses. 

If  it  is  claimed  by  the  defense  that  the  child  was  suffocated  during  the 
bu'th  then  httle  or  no  air  should  be  found  in  the  lungs.  E^ddence  that 
respiration  had  taken  place  increases  the  ]3robabihty  of  death  from  homi- 
cidal causes. 

A  child  may  be  bmied  ahve,  the  mother  claiming  that  it  was  bimed 
after  death.  In  asphyxia  by  burying  the  characteristic  lesions  of  suffo- 
cation are  observed,  and  portions  of  the  same  kind  of  material  that  sm'- 
rounds  the  body  will  generally  be  found  in  the  esojDhagus  and  stomach. 
After  death,  it  may  get  into  the  mouth  or  throat  but  no  farther. 

Infanticide  by  Strangulation. — Among  the  different  methods  most 
frequently  employed  for  the  desti'uction  of  new-born  infants  is  stran- 
giilation.  The  neck  is  constricted  by  ligature  or  by  manual  compression. 
Cases  have  been  recorded  in  which  the  fatal  ligation  was  accomplished  by 
tying  the  umbilical  cord  about  the  throat. 

The  most  conclusive  signs  of  death  by  strangulation  are  the  appear- 
ances at  the  site  of  ligation.  The  mark  of  constriction  is  frequently  ap- 
parent, and  the  superficial  structures  above  and  below  are  ecchymosed  and 
edematous.  The  imprints  of  the  fingers  and  nails  may  be  perceptible. 
When  great  violence  has  been  used,  the  skin  at  the  seat  of  constriction  may 
Tbe  abraded  and  torn  and  the  muscular  structures  contused  and  lacerated. 

The  face  is  usually  congested  and  edematous  and  the  eyes  proti'uded. 
Ecchymotic  spots  are  present  upon  tlie  conjunctiva^ ;  they  ai'e  seen,  how- 
ever, after  death  from  other  causes  than  strangulation.  Extravasations 
of  blood  are  frequently  found  in  the  deeper  structures  on  dissection,  when 
not  visible  to  any  extent  upon  the  surface.  There  is  usually  great  vascular 
engorgement  in  the  lungs,  though  in  a  certain  proportion  of  cases  these 


Anonriox  jxij  lyFJxririDK.  493 

oi'g'ans  present  a  normal  appearance.  Enipliyseniatous  areas  in  the  lunt^s 
and  pulmonary  apoplexies  are  frequently  observed.  The  brain  and  men- 
inj.;'i's  are  violently  congested.  In  general  the  post-mortem  findings  are 
the  same  as  in  the  adult  after  death  by  strangulation.  The  lesions  of 
strangulation,  however,  are  not  easily  differentiated  from  those  of  suffo- 
cation. 

Little  confusion  need  arise  from  the  existenc-e  of  other  marks  upon 
the  body  resembling  those  of  strangulation.  The  nu)ttling  of  the  skin 
Avhicli  is  common  after  death  from  other  causes  is  not  attended  with 
ecchymoses.  The  absence  of  edema  and  venous  engorgement  in  suffoca- 
tion serves  to  distinguish  it  froni  strangulation. 

If  it  be  urged  that  the  injuries  sustained  were  innocently  inflicted  by 
the  mother  in  attempts  to  deliver  herself,  the  answer  will  be  that  at  the 
time  when  such  efforts  would  be  required,  while  the  body  of  the  child 
was  still  x>artly  in  the  uterus,  the  respiratory  function  would  have  been 
maintained  through  the  placenta,  and  strangulation  would  at  that  time  be 
impossible.  Again,  if  the  child  had  died  in  the  act  of  birth  little  or  no 
air  w<.)uld  be  found  in  the  lungs  by  the  usual  test.  Nearly  the  same  ar- 
gument would  apply  in  refutation  of  the  claim  that  the  child  had  died 
■during  birth  from  the  winding  of  the  cord  about  the  neck.  Furthermore, 
it  is  very  rai-ely  that  the  coiling  around  the  neck,  when  accidental,  is  suf- 
ficiently tight  to  strangulate  the  cord. 

Infanticide  by  Precipitation  into  a  Privy  Vault. — Infanticide  by 
precipitation  into  the  vault  of  a  privy  must  be  distinguished  from  cases 
in  which  the  body  has  been  deposited  in  the  priv}^  after  death  for  the  pur- 
pose of  concealment  The  presence  of  night-soil  in  the  air-passages  and 
stomach  may  generally  be  regarded  as  evidence  that  the  child  was  living 
when  it  was  placed  in  the  vault.  If  it,  be  claimed  that  the  woman,  un- 
aware that  the  birth  was  so  near  completion,  had  innocently  expelled  the 
■child  into  the  water-closet,  the  medical  facts  should  accord  A^dtli  this 
■explanation.  If,  for  example,  the  cord  be  found  to  have  been  cut  instead 
of  torn  the  defense  will  be  discredited.  In  some  instances  a  close  inspec- 
tion of  the  ends  of  the  divided  cord  may  be  requii-ed  to  determine 
whether  it  was  sundered  by  incision  or  by  laceration.  The  post-mortem 
appearances  usuallv  present  after  death  by  drowning  should  be  looked 
for. 

Infanticide  by  Drowning. — The  methods  of  child-murder  most  com- 
monly employed  are  those  already  discussed.  Drowning  is  a  mode  of  in- 
fanticide but  seldom  practiced,  yet  a  case  is  mentioned  in  which  a  woman 
caused  the  death  of  her  child  by  getting  into  the  bath-tub  partially  filled 
with  water,  as  the  birth  was  about  to  be  completed,  and  forcibly  holding 
the  head  under  water.  Accidental  drowning,  as  already  stated,  nuiy  result 
from  sudden  and  unexpected  delivery,  by  the  expiilsion  of  the  child  into 
a  privj^  vault.  Not  uncommonly  the  body  of  the  child,  after  destruction 
by  other  means,  is  thrown  into  the  water  for  the  purpose  of  concealing 
the  evidence  of  crime. 

In  all  cases  of  drowning  it  is  extreuu4y  difficult  to  determine  by  the 
medical  evidence  alone  whether  death  was  due  to  accidental  or  crimiual 
causes.  In  case  of  alleged  drowning  careful  search  should  be  nuide  for 
marks  of  violence  such  as  obtain  in  other  homicidal  nu^thods.  The  body 
should  be  examined  for  proofs  of  suffocation  or  strangiilation,  and  for 
other  evidence  of  violence,  accidental   or   criminal.      The  fauces  and 


494  ^   SYSTEM   OF  LEGAL  MEDICIXE. 

tracliea  should  be  searched  for  obstrueting  material  wMch  may  have 
been  placed  there  with  criminal  intent,  as  well  as  for  the  usual  causes  of 
asphyxia  by  accident  in  the  new-born.  The  j^resence  in  the  stomach  of 
hquid  or  other  material  like  that  contained  in  the  vault  would  be  proof 
positive  that  the  child  was  li\"ing  when  thrown  into  it.  These  substances 
could  have  gained  access  to  the  stomach  only  by  the  act  of  swaUowing. 
In  the  dead  body  they  could  go  no  farther  than  the  mouth  and  nares. 

Infanticide  by  Wounds. — When  wounds  are  found  on  the  body  in 
eases  of  alleged  infanticide,  the  medical  witness  will  be  called  upon  to 
testif}"  whether  or  not  the  existing  wounds  were  comj)etent  to  cause  deaths 
and  whether  they  were  inflicted  upon  the  living  child  or  were  post-mortem 
injuries.  The  first  question  will  be  determined  on  general  medical  grounds 
by  the  location  and  extent  of  the  injury.  To  answer  the  second  is  some- 
times dilEcult.  Discolored  patches  upon  the  skin  should  be  dissected  to- 
disting-uish  ecch^^noses  from  the  simple  blue  coloration  which  is  commonly 
seen  about  the  Hjjs  and  nose  of  the  new-born  after  death.  Wounds  re- 
sulting from  labor  usually  occupy  the  presenting  part  of  the  fetus.  Yet 
the  death  of  the  child  may  result  from  luxation  of  the  cervical  vertebrae 
in  unskillful  delivery.  Abrasions,  ecchymoses,  and  even  lacerations  of 
the  skin,  are  frequently  found  after  difficult  births,  even  in  the  absence  of 
instrumental  interference. 

Wounds  inflicted  during  life  are  usually  distinguished  by  the  e"^idence 
of  hemorrhage,  and,  if  the  child  lives  sufficiently  long  after  the  infliction 
of  the  injury,  by  signs  of  repaii-  or  of  inflammatory  action.  Apparently 
insignificant  wounds,  and  even  so  small  as  to  escape  any  but  the  closest 
scrutiny,  may  be  fatal  where  \\tdl  organs  are  involved.  The  wound  may 
pass  undetected  when  the  puncture  is  made  tlu'ough  the  mouth,  the  navel, 
the  orbital  canities,  or  other  natui'al  openings.  These  cavities,  as  well  as. 
the  f ontanelles  and  the  surfaces  overlying  other  ^dtal  organs  of  the  body, 
should  be  carefully  scrutinized.  In  death  by  extensive  wounds  the  body 
may  jjresent  the  marks  of  extreme  anemia  from,  acute  hemorrhage.  In 
case  of  susj)ected  comj^hcity  of  the  medical  attendant  in  the  crime,  the 
fetus  and  the  pehis  should  be  examined  for  e\'idence  of  any  condition  that 
may  have  justified  the  mutilation  of  the  child. 

Fractures  of  the  Skull. — Fractures  of  the  skull  in  the  new-born  are 
not' necessarily  e\'idence  of  homicidal  "\aolence.  They  sometimes  occur 
from  accidents  of  difficult  or  precipitate  labor.  It  is  not  always  possible 
to  distinguish  fractui-es  produced  after  from  those  occurring  before  death. 
A  distinguishing  mark  in  post-mortem  fractures  is  the  almost  complete 
absence  of  bloody  effusion.  This  is  always  present  in  such  injuries  when 
sustained  during  life.  ''  Extravasation  indicates  movement  of  the  blood 
toward  the  part  affected."'  In  case  of  wounds  inflicted  a  sufficient  length 
of  time  before  death,  tlie  signs  of  inflammation  will  be  observed.  Fract- 
ures fi-om  the  pressiu-e  of  the  peMc  walls  upon  the  head  during  the  birth 
are  of  extremely  rare  occurrence.  Such  cases,  howeA^er,  have  been  re- 
corded. Depressions  of  the  skull  by  the  sacro-vertebral  promontoiy  in 
deformed  pelvis  are  situated  on  the  anterior  part  of  one  parietal  bone  or 
on  the  frontal  or  the  temporal  near  the  parietal.    They  are  seldom  fatal. 

Skull  fractui'e  in  the  new-born  from  other  causes  than  criminal,  as 
has  been  seen,  ma}-  result  from  unexpected  delivery  while  the  woman  is  in 
the  standing  postm^e.     A  full  liistory  of  the  confinement  wiU  ob\dously 


ABOBTWX  AND   INFANTICIDE.  495 

form  an  essential  part  of  the  data  upon  wliich  the  conclusions  of  the  expert 
are  to  be  based. 

Infanticide  by  Neglect. — Under  this  head  are  to  be  mentioned  expos- 
ure to  cold,  starvation  from  willful  omission  to  feed,  and  purposely  neg- 
lected aiicidents. 

Examination  after  death  resulting  from  exposure  to  cold  will  reveal 
nothing  pointing  specifically  to  the  fatal  injury,  yet  it  will  be  important 
for  the  purpose  of  deciding  whether  or  not  an  explanation  of  the  dcatii 
may  be  founded  on  other  grounds.  In  death  from  this  cause  the  lungs 
contain  air,  showing  that  the  child  had  breathed.  The  body  presents  no 
marks  of  violence.  The  entire  absence  of  food  in  the  digestive  tract  would 
raise  the  question  of  death  by  starvation.  Death  would  not  occur  from 
the  latter  cause  alone  in  less  than  a  week,  and  the  body  would  be  greatly 
emaciated. 

The  child  may  die  of  asphyxia  from  willful  neglect  to  remove  the 
tightly  coiled  funis  from  the  neck ;  it  may  purposely  be  allowed  to  lie  with 
its  face  in  a  pool  of  liquids  discharged  from  the  bii'th  canal;  or  umbilical 
hemorrhage  may  proceed  to  a  fatal  termination  in  consequence  of  omission 
to  tie  the  cord.  Even  the  failure  to  obtain  medical  aid  in  asphyxia,  con- 
vulsions, or  other  maladies  of  the  new-born,  when  they  terminate  fatally, 
must  be  classed  among  the  criminal  causes  of  death  if  willful  neglect  can 
be  proven. 


GENITO-UEINAEY  AND  VENEEEAL  AFFECTIONS  IX 
THEIE  MEDICO-LEGAL  EELATIOXS. 


BY 

F.   E.    STURGIS,   M.D. 


In  the  article  whicli  has  been  assigned  to  me  I  propose  to  consider 
the  affections  of  the  geuito-iu'inary  organs  in  men  and  women  in  their 
bearing  npon  the  marital  relation,  and  the  resnlts  which  venereal  diseases 
— and  by  these  I  mean  gonorrhea  and  s^^hihs — have  upon  the  bearers  of 
the  diseases  as  well  as  upon  theii*  offspring.  To  properly  discuss  the 
effects  of  these  diseases  in  their  medico-legal  relations  I  projDOse  to 
divide  them  into  the  following  gi-oups : 

First.  Impotence  in  the  male. 

Second.  Impotence  in  the  female. 

Third.  Sterilit}^  in  the  male. 

Fourth.  Sterility  in  the  female. 

Fifth.  The  effects  of  gonorrhea  in  its  sexual  relations;  and 

Sixth.  The  effects  of  sj^hilis  upon  the  bearers  of  the  disease  and 
upon  the  children  which  may  be  born  to  them. 

My  portion  of  this  article  wiU  be  entii'ely  confined  to  the  medical  side 
of  these  affections. 

Impotence  in  the  Male. — This  affection  is  due  to  two  causes,  one 
pliysical,  the  other  psychical,  the  first  having  its  origin  entirely  in  some 
physical  malformation  or  physiological  perversion,  congenital  or  other- 
wise, and  the  other  depending  upon  mental  distiu'bances  or  impressions, 
whether  originating  from  without  or  within  the  patient's  mind.  The 
physical  causes  are  the  ones  which  I  shall  first  examine,  and  those  of  the 
penis  are  the  foremost  to  invite  attention. 

Sometimes  there  is  a  congenital  absence  of  the  viiile  organ,  while  all 
the  other  parts  are  more  or  less  perfect  (entii'ely  apart  fi-om  any  ques- 
tion of  hermapliroditism),  the  man  being  in  perfect  health,  with  all  the 
external  symptoms  of  ^drility  such  as  are  apparent  in  the  face  and  in  the 
contour  and  shape  of  the  body.  The  scrotmn  is  present,  with  the  testes 
in  their  normal  place,  but  at  the  spot  where  the  penis  should  be  nothing 
is  apparent.  The  urethra,  in  these  conditions,  usually  opens  behind  the 
scrotum,  in  the  perineum,  as  a  small  opening  concealed  by  a  fold  of  skin, 
sometimes  seated  behind  a  little  excrescence,  looking  like  a  cockscomb, 
and  comnninicates  directly  with  the  bladder,  simulating  somewhat  the 
appearance  of  tlie  fenuile  meatus.  It  will  l)e  noted  that  in  this  case 
there  can  be  no  question  of  hermaphroditism.     There  is  no  appeai-auce 

497 


498  -4  SYSTEM  OF  LEGAL  MEDICINE. 

-or  simulation  of  any  of  the  female  genitalia,  the  subject  being,  to  all 
intents  and  piurposes,  a  man,  except  that  he  has  no  penis. 

Sometimes,  however,  the  condition  of  things  does  not  go  qnite  so  far 
as  entire  absence.  In  this  case  the  malformation  may  be  simply  in  the 
diminutive  si^e  of  the  penis,  which  varies  from  half  an  inch  to  two  inches 
in  leng-th,  and  is  capable  of  more  or  less  complete  erection,  unless  it  be 
tightly  bound  to  the  scrotum.  Under  such  cii'cumstances  the  subject  need 
not  necessarily  be  impotent.  He  is  capable  of  intromission  within  a  cer- 
tain distance,  and,  pro"\dding  the  ejaculation  of  the  spermatic  fluid  be  com- 
plete, the  man  may  be  the  father  of  a  family.  Excessive  smallness  of 
the  penis  is  not,  therefore,  a  bar  to  the  completion  of  the  sexual  act  nor 
to  the  exercise  of  marital  duties ;  but  the  condition  is  different  in  those 
cases  known  as  a  palmate  penis — that  is  to  say,  where  the  penis  is  adher- 
ent to  the  anterior  raphe  of  the  scrotum  and  where  it  is  then  bound 
down,  mechanically,  during  any  attempts  at  erection.  This  condition  of 
affans  is,  however,  easily  remedied  by  freeing  the  penis,  when  the  jjhysi- 
ological  functions  of  the  organ  are  restored  to  then-  normal  condition. 

The  opposite  condition  may  also  act  as  a  bar  to  the  sexual  act,  where 
the  penis  is  inordinately  large — and  I  do  not  mean  enlarged  from  ele- 
phantiasis, but  where  the  whole  organ  seems  to  be  abnormally  and 
equally  developed,  and  where  intromission  into  any  ordinary  vagina  is 
impossible.  Under  these  circumstances  the  man,  although  capable  of 
complete  erection  and  of  the  performance  of  the  sexual  act,  is  impotent 
from  the  disparity  between  his  genitals  and  those  of  the  average  woman. 

Another  cause  of  masculine  impotence  is  due  to  the  fact  that  the 
penis  is  sometimes  double  for  a  greater  or  less  extent  of  its  length,  each 
organ  ha^ing  its  own  urethra.  These  unite  posteriori}-  into  one  canal 
and  one  i^enis,  finding  theii'  termination  in  a  single  Ijladder,  both  organs 
from  their  point  of  bifurcation  emitting  two  streams  of  equal  size  during 
micturition  and  being  capable  of  double  seminal  emission.  Under  such 
cu'cumstances  it  is  possible  that  a  man  may  have  connection,  as  is  noted 
in  the  case  of  a  patient  reported  by  Isidor  G-eoffroy  St.  Hilaire.  This 
man,  it  is  stated  in  the  report,  never  engendered  anjiihing  but  twins. 
This  last  statement  I  do  not  claim  to  pass  judgment  uj)on,  as  it  seems  to 
me,  unless  two  ova  were  deposited  in  the  uterus  at  the  same  time  for 
fecundation,  that  it  would  make  little  difference  how  many  virile  organs 
entered  the  woman  at  the  same  connection. 

Another  reason  for  the  non-performance  of  the  sexual  act  is  due  to  a 
curious  malformation  which  has  been  noted  by  many  writers,  viz.,  that 
at  some  portion  of  the  penis  a  deposit  occui'S  in  the  corpora  cavernosa 
which  prevents  the  complete  distention  of  the  organ.  Sometimes  this 
results  from  calcareous  deposits,  from  inflammation  (gonorrheal  or  sim- 
ple), or  fi'om  an  injury  done  to  the  organ  by  ''breaking  a  chordee,''  as  it 
is  called,  and  sometimes  from  s^^^hihtic  exudations.  Where  it  results 
from  gonorrhea  or  syphilis  it  is,  as  a  rale,  curable,  but  where  it  is  caused 
by  \dolence  or  injury  done  to  the  canal,  or  where  it  occurs  idiopathically, 
little  can  be  done  by  treatment,  although  some  cases  are  reported  to  have 
recovered  spontaneously.  Under  these  circmnstances  the  penis  is  turned 
either  to  one  side  or  the  other,  or,  as  I  have  seen  it  in  one  instance,  where 
the  exudation  was  annular,  one  half  of  the  penis  remained  entirely  flac- 
cid wliile  the  posterior  half  was  erect.  Intromission  and  sexual  inter- 
course are  usually  impossible,  although  if  the  jjenis  be  merely  twdsted, 


GENITO-URINABY  AND    VENEREAL  AFFECTIONS.  499 

-while  erection  is  comjjlete,  coitus,  witli  a  little  maiia^emont,  may  be 
accomplished. 

Again,  besides  these  path()h)<i'i{'al  eaiisrs  there  may  T)e  complete  tor- 
sion of  the  penis  npon  its  axis  during-  eivetion,  as  is  noted  in  the  case 
reported  by  Guerlain  {Bulletin  de  Ja  t^ociete  Anatotniqae,  1859,  2^  serie, 
t.  iv.,  p.  27),  in  which  the  penis,  dnring  erection,  was  completely  rotated 
in  such  a  manner  that  the  dorsum  of  the  penis  became  the  nnder- surface, 
looking  backward  toward  the  scrotum,  while  the  urethral  aspect  was 
turned  uppermost  and  a  little  to  the  left. 

Sometimes  the  corpora  cavernosa  present  anomalies,  either  being 
atrophied  or  even  going  so  far  as  to  be  completely  absent.  Such  a 
•case  is  reported  by  Delbarier  {Annales  de  la  Mklecim  Beige,  1842,  Mai,  5^ 
Cahier,  p.  10). 

In  most  of  the  malformations  considered  above,  it  is  apparent  that 
the  i3atient  would  be  impotent  from  purel,y  physical  causes,  without  the 
mind  exercising  any  influence  as  regards  the  sexual  act.  Another  vari- 
ety of  phj'sical  deformity  which  sometimes  acts  as  a  bar  to  complete 
coitus  is  seen  in  cases  of  hypospadias.  Epispadiacs,  as  a  rule,  are  capa- 
ble of  copulating  properly,  notwithstanding  that  their  sexual  oi'gans 
may  not  be  perfectly  normal,  and  the  same  is  true,  to  a  certain  extent, 
among  hypospadiacs.  Provided  that  the  In^pospadias  be  in  the  anterior 
portion  of  the  urethra,  in  such  a  position  that  during  emission  the  semen 
€an  be  ejaculated  within  the  labia  majora,  coitus  will  be  successful;  but 
where  the  hypospadias  is  far  back,  say  at  the  penoscrotal  or  behind  the 
perineoscrotal  angles,  the  emission  which  takes  place  of  course  does  not 
reach  the  vagina,  nor  even  probably  the  external  vulvar  lips  in  the  female, 
and  therefore  becomes  of  no  effect.  Sometimes  these  cases  are  remedia- 
ble, in  others  not ;  and  of  course  when  the  latter  condition  obtains,  the 
patient  will  have  to  be  classed  among  those  who  are  i3liysieally  impotent. 

Phimosis,  partieulai'h"  if  congenital  and  adherent  to  the  surface  of  the 
gians  penis,  or  where  the  orifice  is  exceedingly  small,  may  sometimes  be 
the  cause  of  impotence  in  the  male,  by  preventing  the  emission  of  the 
semen  into  the  vagina,  the  entire  charge  being  pocketed  in  the  elongated 
and  distended  prepuce  and  only  being  evacuated  by  the  manual  interfer- 
ence of  the  patient.  In  the  majority  of  instances,  unless  the  adhesions 
are  exceedingl}'  firm  and  extensive,  the  evil  may  be  remedied  by  circum- 
cision. 

Stricture  of  the  urethra,  when  seated  far  back  and  when  tight,  often- 
times acts  as  a  bar  toward  the  completion  of  the  sexual  act,  and  I  have 
seen  cases  in  which  the  stricture  was  so  tight  that  during  the  excitement 
and  tiu-gescence  consequent  upon  the  copulation  the  entii-e  seminal  chs- 
charge  was  forced  backward  into  the  l)ladder,  but  a  few  drops  escaping 
jier  uretlwam  during  the  act.  The  first  micturition  after  the  act  showed 
the  urine  full  of  spermatozoa.  The  patients  in  these  cases  always  com- 
l)lain  of  a  great  fullness  in  the  perineum,  sometimes  aceom2:)anied  with  a 
momentary  sensation  of  sharp  paiii,  probably  due  to  the  enormous  dis- 
tention of  the  urethra  at  a  point  Avhere  the  obstruction  was  present,  and 
'^vhicl^  was  relieved  as  soon  as  the  semen  foimd  its  way  backwai-d. 

Anomalies  of  the  testicle  are  another  cause  of  impotence,  and  in  these 
instances  they  may  be  such  as  to  lead  to  a  condition  of  azoospermatism 
in  which  healthy  spermatozoa  are  not  secreted.  This  is  especially  noticed 
in  the  case  of  monorchids  in  whom  the  testicle  is  retained  in  the  abdo- 


500  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

men  or  at  tlie  mg'iiiual  ring.  "UTiere  tliis  occiu's  the  j)atient  is  not  only 
sterile,  bnt  he  also  is  impotent:  the  erections  are  incomplete  or  evanes- 
cent, and  whatever  seminal  discharge  there  is.  ejaculation  occurs  so  pre- 
maturely that  frequently  the  patients  have  finished  the  sexual  act  before 
gaining  entrance  into  the  "woman. 

Sometimes  the  testes  are  found  to  be  congenitally  atrophied.  In  an 
interesting'  case  given  by  Roubaud  {Tvaite  de  VImpuissance  ef  cle  la  Sferi- 
life,  p.  161),  the  patient,  twenty  yeai-s  of  age,  showed  a  penis  which,  on  erec- 
tion, was  about  the  size  of  a  poi'cupine's  qiiUI  and  only  two  inches  in 
length,  and  in  whom  the  testes  had  only  attained  the  size  of  a  hazelnut : 
and  these  latter,  upon  contraction  of  the  scrotum,  would  disappear 
entirel}^  into  the  iugiunal  canals. 

Atrophy  may  also  result  as  a  consequence  of  gonorrheal  epididymitis^ 
varicocele,  and  s^'philitic  orchitis,  and  in  all  thi*ee  affections  the  atrophy 
is  usually  permanent  and  past  ciu-e. 

The  question  of  hermaphroditism  natui-ally  presents  itself  in  these 
cases  of  sexual  perversion,  but  so  far  as  then-  sexual  aspects  are  con- 
cerned they  need  not  concern  the  siu-geon,  for  the  simple  reason  that  in 
nearly  all  instances  the  hermaphi'odite  may  be  classed  as  either  male  or 
female,  and  a  careful  examination  should  enable  the  surgeon  to  place  the 
hermaphi'odite  as  either  a  man  or  woman.  The  crucial  tests  in  these 
cases  are  the  presence  or  absence  of  the  eatamenia  and  the  presence  or 
absence  of  the  sexual  emissions ;  and  where  one  or  the  other  of  these 
functions  can  be  shown  to  exist  the  establishment  of  the  patient's  sex 
follows  as  a  natural  consequence.  Some  cases  are  spoken  of  as  being* 
neuters,  in  whom  the  sexual  condition  seems  to  be  so  evenly  di-^ided  as 
to  make  it  difficult  of  decision ;  but  such  cases  are  very  rare  indeed,  and  I 
am  myself  strongly  disposed  to  doubt  their  existence.  Occasionally,  in 
the  ease  of  female  hermaphrodites,  the  surgeon  will  be  sometimes  puzzled 
by  being  told  that  the  eatamenia  have  never  appeared :  but  upon  careful 
examination  in  these  instances,  where  all  other  indications  point  toward 
the  feminine  sex  of  tlie  patient,  the  monthly  discharge  of  blood  wdl  be' 
found  to  issue  fi-om  some  portion  of  the  body  outside  of  the  sexual 
organ — in  other  words,  they  are  eases  of  vicarious  menstruation. 

Besides  the  physical  causes  for  impotence  in  the  male  just  enumer- 
ated, the  mental  condition  of  the  patient  sometimes  operates  to  prevent 
normal  coitus.  Those  who  have  much  to  do  with  the  treatment  of  sexual 
disorders  in  the  male  have  been  struck  with  the  ciu-ious  phases  which 
this  mental  condition  sometimes  assumes.  For  example,  some  men  who 
are  perfectly  well  formed,  vigorous,  healthy,  and  capable,  as  has  been 
shown  by  experience,  of  performing  the  sexual  act.  are  rendered  com- 
pletely impotent  unless  the  usual  conditions  to  which  they  are  accustomed 
are  all  fulfilled  at  the  time  of  connection.  One  most  curious  instance  of 
this  mental  condition  is  given  by  Roubaud  (oj).  cif.,  p.  439  et  seq.),  in  which 
the  patient,  when  a  boy  of  foui'teen  yeai's  of  age,  was  seduced  by  a 
female  friend  older  than  liimseK,  a  member  of  his  family.  The  girl 
herself  was  a  pronounced  blonde,  wore  ringlets,  and  inasmuch  as  the 
forbidden  j)leasure  had  to  be  done  by  stealth  their  amorous  relations 
were  accomplished  when  both  Avere  fully  dressed.  These  relations  lasted 
for  some  time,  and  the  young  man  finally  left  home  and  went  into  the 
army.  Upon  trying  subsequently  to  perform  the  sexual  act,  he  found  to 
his  extreme  astonishment  that  every  woman  was  repugnant  to  him  un- 


GEXITO-rniXAliY  AXD    VEXKUEAL    AEFECTIOXS.  jQl 

less  she  was  a  blonde,  Avore  her  liair  in  ringlets,  and  Avas  fully  dressed. 
Under  these  circnnistanees  he  eonld  perform  the  sexual  aet  witli  vitrftr 
and  complete  satisfaction,  but  for  another  kind  of  a  woman,  brunettes 
especially,  and  nnder  any  other  conditions,  as,  for  example,  when  un- 
dressed and  in  bed,  he  had  such  an  aversion  that  he  was  practically 
impotent.  Such  was  the  force  of  imagination  and  of  habit  upon  his 
sexual  powers.  Now  the  sequel  is  just  as  cmious.  "Witli  the  perversity 
of  hunum  nature,  he  fell  in  love  with  a  brunette,  and  it  was  this  unfortunate 
condition  of  affairs  that  induced  him  to  consult  Koul»aud,  who  gave  him 
a  potion  which  he  told  him  to  take,  and  bade  him  nuike  an  attempt  at 
coitus  with  the  brunette  two  hours  after  its  ingestion,  assuring  him  of 
success.  The  draft  was  taken,  the  nuiu  went  to  bed,  and  although  no 
coitus  was  attempted  at  that  time  the  patient  had  dm-ing  the  whole 
night  a  violent  erection,  with  strong  sexual  desire.  Apparently,  from 
the  history  of  the  case,  the  reason  why  coitus  was  not  attempted  was 
from  the  fear  that  it  would  prove  a  failure.  However,  the  next  day  he 
consulted  M.  Roubaud  again  and  "VA^ished  to  know  if  he  might  use  the 
draft  a  second  time.  luasnnich  cis  it  contained  a  large  dose  of  can- 
tharides,  M.  Rouliaud  refused  to  give  his  permission,  but  substituted 
another  one  in  which  the  amount  of  cautharides  was  very  much  reduced^ 
and  told  the  patient  to  take  that.  The  man,  ha\-ing  been  convinced  that 
he  had  at  last  obtained  an  agent  which  would  at  least  overcome  the 
physical  results  of  his  aversion  to  bimnettes,  took  the  second  draft, 
and  going  to  bed  with  the  woman  the  second  night  accomplished  his  pur- 
pose and  thus  conquered  his  curious  and  seemingly  irrational  aversion 
to  brunettes  or  to  attempting  the  sexual  act  except  when  fully  dressed. 

This  is  an  extreme  instance  of  what  mental  imjiressious  will  do  in 
causing  i3erversion  of  the  sexual  functions  ;  but  not  infrequently  surgeons 
are  consulted  by  patients  who  state  that,  while  the  sexual  desii-e  is  strong 
up  to  the  point  of  going  to  bed,  the  moment  coitus  is  attempted  the 
erection  disappears  and  vdth.  it  all  possibility  of  iutercoui'se.  The  same 
condition  often  ensues  fi'om  the  unreasonal.)le  fear  that  the  attempted 
connection  will  end  in  failure.  There  is  uo  physical  reason  for  this- 
dread :  the  patient  is  i:)erfectly  capable  of  performing  the  sexual  act :  and 
3'et  when  he  is  with  the  woman  he  is  perfectly  useless  as  a  liedfellow ; 
and  oftentimes  the  mere  dread  of  failure,  if  failure  has  once  occm-red  ou 
attempting  coitus,  puts  an  end  to  all  futm-e  attempts.  There  is  often  a 
physical  cause  for  this  mental  disturl)ance,  such,  for  instance,  as  hyper- 
testhesia  of  the  deep  portions  of  the  urethra,  slight  and  irritable  urethral 
strictures,  hemorrhoids,  fissures  of  the  anus  and  rectum,  or  a  subacute 
inflammation  of  the  neck  of  the  bladder ;  and  the  well-informed  surgeon 
-will  carefully  search,  in  such  cases,  for  any  physical  cause  to  account 
for  the  patient's  sexual  condition,  and  if  such  exists,  by  remoAing  the 
physical  cause  cure  the  sexual  disturbance. 

Glycosuria  is  another  of  the  causes  which  are  mentioned  as  a  possible 
source  of  impotence  in  the  male,  particularly  in  the  latter  stages,  when 
all  sexual  desire  and  all  sexual  power  seem  to  be  either  in  abeyance  or 
else  completely  lost,  and  in  addition  there  also  appears  to  be  a  diminu- 
tion in  the  amount  of  the  semen  secreted. 

Renal  diseases,  especially  that  condition  of  the  kidneys  kno\Ani  as 
atrophy,  intinmmation  of  the  prostate,  especially  when  associated  witli 
marked  hypertrophy,  and  alfections  of  the  neck  of  the  bladder,  coexist- 


502  A   SYSTEM  OF  LEGAL  MEDICINE. 

ing  or  associated  with  the  prostatic  hypertrophy,  maj  all  be  causes  of 
impotence  in  the  male  and  interfere  materially  with  sexual  desire  as 
well  as  with  erection. 

Eversion  of  the  bladder  is  another  cause  of  impotence,  not  so  much 
on  account  of  the  protrusion  and  eversion  of  this  viscus,  but  from  the 
fact  that,  associated  with  it,  there  is  very  often  a  malformation  of  the 
penis,  usually  either  complete  hypospadias  or  epispadias.  In  one  instance 
which  I  have  seen  latelj^,  the  patient  was  entirely  epispadiac,  the  lower 
portion  of  the  penis  being  fairly  well  formed,  but  the  upper  portion  was 
entirely  wanting.  The  urine  was  secreted  by  the  bladder  and  ran  into  a 
gutter  which  was  formed  of  the  inferior  portion  of  the  urethra.  The 
corpora  cavernosa  were  imperfect,  and  he  never  had  any  erections,  al- 
though he  stated  that  he  occasionally  had  sexual  desires,  but,  of  course, 
without  any  possibility  of  gratifying  them. 

Sometimes  the  lack  of  erection  appears  due  to  an  imperfect  circula- 
tion of  the  blood  in  the  penis,  and  I  am  of  the  opinion  that  it  is  generally 
associated  wdth  some  congestion  of  the  deeper  portion  of  the  urethra 
(usually  prostatic),  with  prostatic  enlargement  or  mth  some  inflamma- 
tion of  the  neck  of  the  bladder. 

Sexual  debility  and  impotence  have  often  been  ascribed  to  masturba- 
tion, and  undoubtedly,  if  the  habit  be  resorted  to  iutemperatety,  it  may 
weaken  the  sexual  power ;  but  I  am  by  no  means  in  accord  with  those 
writers  who  regard  the  masturbation  of  early  youth,  as  generally  prac- 
ticed by  boys  and  adolescents,  as  a  cause  of  serious  sexual  disorder  later 
in  life.  A  great  deal  of  the  functional  disturbance  which  occiu-s  in  these 
cases  is  due  to  the  mental  impressions  made  by  reading  the  various 
books  and  articles  which  describe,  in  glowing  and  fearful  terms,  the 
sexual  penalties  which  the  masturbator  paj^s  for  his  trifling  amusement, 
and  to  the  fact  that  masturbators  very  frequentl}^  suffer  from  deej)- 
seated  urethral  inflammations,  situated  about  the  bulbus  urethra,  and 
from  there  extending  backward  toward  the  bladder.  These  disorders 
are  purely  functional  and  generally  yield  to  appropriate  and  rational 
treatment ;  though  evanescent  in  character,  they  nevertheless  are,  to  all 
intents  and  puiposes,  while  they  last,  as  serious  a  cause  of  impotence 
as  though  this  latter  was  due  to  some  organic  defect. 

Impotence  in  the  Female. — The  female  being  a  passive  agent  in  the 
copulative  act,  impotence  in  her  plays  a  minor  part  as  compared  with 
that  of  her  more  active  partner.  The  principal  causes  of  impotence  in 
the  female  are  those  of  an  organic  natiu^e,  as,  for  example,  where  the 
vulva  is  absent,  where  the  vagina  is  absent,  or  where  the  vagina  ends,  as 
it  does  in  some  instances,  either  in  the  bladder  or  in  the  rectum,  consti- 
tuting a  vesicovaginal  and  rectovaginal  malformation.  Impotence,  there- 
fore, is  partial  or  complete  according  to  the  nature  of  the  organic  lesion, 
being  complete  where  there  is  absence  of  the  vulva  or  vagina,  and  in- 
complete if  the  vagina  be  moderately  developed — that  is  to  say,  if  it  be 
two  inches  in  length ;  and  instances  have  been  known  where  coition  has 
been  complete  in  still  more  undeveloped  vagina?.  Of  course  connection 
is  more  complete  in  the  instances  where  the  vagina  is  more  nearly  normal 
in  length,  but  ends,  perhaps,  in  the  bladder  or  rectum. 

Absence  of  the  uterus  would  not  constitute  a  bar  to  perfect  coitus  so 
far  as  the  female  is  concerned,  but  would  constitute  another  kind  of 
trouble  which  I  shall  consider  when  I  speak  of  sterility. 


GENITO-UBINAIiY  AND    VENEREAL  AFFECTIONS.  503 

In  tlie  woman,  as  in  the  man,  extroversion  of  the  bladder  would  also 
l)e  a  bar  to  intercourse,  especially  if,  as  is  sometimes  the  case,  there  is  an 
extroversion  of  the  anterior  vaginal  wall,  what  would  be  the  posterior 
wall  of  the  bladdei-  foi-ming-  the  anterior  Avail  of  the  vagina ;  and  in  these 
cases  very  often  there  is  an  absence  of  the  uterus,  so  that  the  canal  is 
practically  undeveloped. 

Besides  these  causes  of  impotence  in  the  female,  the  question  arises 
how  far  an  imperforate  hymen  may  act  as  a  bar  to  coitus.  This  mem- 
brane has  been  supposed  to  stand  as  the  symbol  of  virginity,  and  its 
absence  to  be  suspicious  of  antenuptial  impurity ;  but  such  is  by  no 
means  the  case.  Hymens  differ  very  much  with  regard  to  theii*  tough- 
ness and  the  completeness  with  which  thej^  protect  the  vaginal  ojjeniug. 
Some  are  very  slight,  trifling  bands  of  tissue  placed  at  the  entrance  of 
the  vagina,  and  are  easily  broken  by  an  accident,  such  as  a  sudden  fall, 
violent  and  excessive  horseback-riding,  physical  exercise,  etc. ;  others, 
again,  are  exceedingly  tough  and  resistant,  so  much  so  that  when  the 
time  arrives  for  the  final  consummation  of  the  marriage  the  man  finds 
liimself  baffled  in  every  attempt  to  gain  entrance.  This  resistance  may 
be  so  marked  that  nothing  short  of  a  surgical  operation  \\aLl  remove  the 
difficulty,  and  it  is  mentioned  here  as  it  has  occasionally  been  made  the 
starting-point  of  proceedings  for  dissohdng  a  marriage.  But,  fortu- 
nately, it  need  not  proceed  to  this,  because  a  simple  surgical  operation 
will  usually  suffice  to  ob\date  the  difficulty. 

Another  symptom,  which  is  more  serious  and  important,  is  that  which 
is  known  as  vaginismus,  a  peculiarly  irritable  condition  of  the  vulva  and 
the  introitus  vaginte,  which  causes  in  the  woman  extreme  pain  upon 
every  attempt  at  coitus,  and  this  pain  is  sometimes  so  excessive  as  to 
induce  a  perfect  horror  at  the  idea  of  sexual  intercourse,  and  terror  at 
the  approach  of  her  husband.  Under  such  circumstances,  if  the  case,  as 
occasionally  happens,  is  incurable,  the  question  might  arise  whether  the 
man  might  not  be  justified  in  seeking  a  divorce  on  the  ground  of  the 
wife's  incapacity  for  carrying  out  the  marital  contract,  and  cases  are  on 
record  in  which  such  a  "view  has  been  sustained. 

Another  curious  malformation,  which,  howcA^er,  need  not  necessarily 
be  a  bar  to  the  complete  consummation  of  the  marriage,  is  that  in  some 
women  the  A'agina  and  uterus  are  double,  sometimes  the  \T.LLva  also ;  but 
in  all  these  instances  one  of  these  passages  seems  to  be  more  used  than 
the  other,  sometimes  entirel}^  so,  and  the  woman  may  even  have  children 
under  those  circumstances.  Each  vagina  and  each  uterus  seems  to  be 
perfect  in  itself,  and  appears  to  be  analogous  in  the  female  to  what  a 
double  penis  is  in  the  male,  only  that  in  the  female  there  is  less  impedi- 
ment to  the  sexual  act. 

There  are  occasional  instances  where  hysteria,  pure  and  simple,  seems 
to  play  a  part  in  preA'enting  coitus,  which  are  analogous  to  the  psychical 
impotence  of  the  male.  Such  cases,  where  unassociated  ^\\{\\  any  phys- 
ical defect  or  deformity  in  the  female,  are  rare.  They  are  usually  con- 
joined with  the  condition  of  affairs  which  has  been  described  under  the 
head  of  Aaiginismus,  and  in  many  instances  a  cure  of  the  physical  defect 
is  a  key  to  the  remedy  of  the  entire  ti-ouble. 

Sterility  in  the  Male. — This  occurs  in  all  affections  of  the  testes  in 
Avhicli  the  secretion  or  elimination  of  the  spermatozoa  is  interfered  Avith. 
It  may  be  due  to  the  absence  of  these  bodies,  either  congenital  or  acci- 


50 J:  A  SYSTEM   OF  LEGAL    MEDICINE. 

dental  (from  injuiy  or  from  ablation) :  Ijut  there  are  causes  wMcli  inter- 
fere with  the  ti-ansmission  of  the  fully  formed  spermatozoa  fi'om  the 
testicle  to  the  vesieulte  seminales,  although  the  testes  may  be,  to  all 
outward  appearances,  perfectly  sound  and  healthy,  this  interference 
being  due  to  a  blocking  up  of  the  vasa  deferentia  from  the  following- 
causes  : 

1.  The  most  frequent  is  gonorrheal  epididymitis. 

2.  Syphilitic  epidid^Tnitis. 

3.  Tubercular  epididj-mitis. 

4.  S^^jhilitic  orchitis. 

5.  Tubercular  orchitis. 

6.  Cancerous  or  sarcomatous  orchitis. 

7.  Atrophy  fi'om  an  injury  or  a  blow :  and 

8.  Atrophy  fi-om  a  long-standing-  varicocele. 

In  addition.  I  think  that  varicocele,  except  in  its  earlier  stages,  inter- 
feres veiy  markedly  with  the  act  of  coition,  and  that  it  finally  results  in 
the  production  of  both  impotence  and  steiihty ;  and  I  beg  the  reader  to 
note — what  perhaps  I  have  not  said  in  so  many  words — that  there  is  a 
difference  between  impotence  and  steidhty.  A  man  may  be  impotent 
and  yet  perfectly  fimitful,  and,  on  the  other  hand,  a  man  may  be  per- 
fectly potent  and  yet  unfruitful.  Steiihty  is  entirely  separate  from  the 
question  of  impotence,  and  depends  upon  any  cause,  whatever  its  origin,, 
which  interferes  either  ^^ith  the  secretion  of  the  sj^ermatozoa  or  T\ith 
their  transmission  fi-om  the  testes  to  the  natural  receptacle  for  their 
storage. 

Sterility  may  be  temporaiy,  as,  for  example,  in  cases  where  men  in- 
dulge excessively  in  either  mastiu-bation  or  in  venerv,  and  in  these  cases- 
the  semen,  if  examined,  will  be  found  to  become  gradually  diminished  in 
quantity  and  less  endowed  with  spermatozoa.  These  bodies  are  imper- 
fectly formed  and  are  oftentimes  broken,  and  in  cases  where  the  debility 
is  extreme  the  semen  is  composed  of  a  thin,  viscid  fluid  filled  with  colloid 
bodies  and  exliil)iting  no  spermatozoa  at  all.  This  condition,  unless  thq, 
disorder  is  deep-seated,  is  u.sually  amenable  to  treatment  and  one  from 
which  the  patient,  in  time,  recovers.  Such  cases  need  not  have  any 
important  bearing  so  far  as  the  medico-legal  aspect  of  the  case  is  con- 
cerned. 

Sterility  in  the  Female.— One  of  the  chief  factors  of  sterility  in  the 
female  is  absence  of  the  ovaries,  either  congenital  or  acquired — that  is  to 
•say,  due  to  a  surgical  operation.  Under  such  cii"cumstances,  of  course^, 
a  woman  is  no  longer  fi-uitful  and  is  incapable  of  bearing  children. 

Other  causes  of  sterility  in  the  female  are  extreme  version  or  flexion 
of  the  uterus,  in  which  the  cer%ical  canal  is  so  much  occluded  that  the 
spermatozoa  are  prevented  from  entering  the  uterine  canity. 

Another  sonrce  of  sterility  in  the  female  seems  to  be  due  to  an  ex- 
ceedingly acid  condition  of  the  uterhie  and  vaginal  secretions,  in  which 
the  spermatozoa  are  killed  abnost  immediateh'  or  shortlj-  after  being 
deposited  in  the  vagina  and  in  the  cervical  canal,  and  so  fail  either  to 
find  their  way  into  the  body  of  the  utenis,  or  else,  if  they  do  find  a  lodg- 
ment there,  practically  arrive  in  a  dead  or  d}ing  condition. 

In  these  cases,  both  of  impotence  and  sterility  in  the  two  sexes,  some 
would  undoubtedly,  in  a  medico-legal  sense,  be  a  bar  to  any  question  of 
matrimony,  and  perhaps  might  be  a  just  reason  for  divorce,  where  the 


GEXITO-UniXARY  AM)    VEXEREAL   AFFECTIOXS.  505 

impotence  or  stci-ility  was  dependent  upon  causes  inii)Ossil)le  of  removal. 
But  in  many  cases  theses  affections  are  remediable,  and  a  return  to  health 
would  ensue  not  only  if  tliese  conditions  supervene  after  marriage,  hut 
even  if  they  are  coincident  with  matrinujuy,  particularly  where  tlie  cause 
is  complicated  with  sexual  or  nervous  disturbance — I  am  getting  mw'e 
and  moi'e  to  regard  these  cases  of  mental  disturbance  as  dependent  ujjou 
a  physical  basis — and  it  then  becomes  a  nice  question  to  decide  how  far 
the  surg(!()n  is  justified  in  advising  matrimony  as  an  assistance  to  the 
<un'e,  and  how  far  ho.  is  propi^i-ly  bound  to  counsel  his  patient  against 
matrimony  in  order  to  prevent  unhappiness  to  both  parties  to  the  marital 
contract. 

Venereal  Diseases  of  Both  Sexes,  in  Adults  and  Children. — For 
the  purposes  of  tliis  article  I  shall  consider  only  two  venereal  diseases, 
gonorrhea  and  syphilis ;  and  I  shall  take  up  first  the  consideration  of  the 
<lisease  as  it  appears  in  the  male,  and  its  consequences ;  next,  the  malady 
as  it  appears  in  the  female,  and  its  consequences ;  and  lastly,  the  results 
upon  tlieir  offspring. 

Gonorrhea,  or,  as  it  is  frequently  called,  urethritis,  which  is  perhaps  a 
l)etter  name,  is  simply  a  catarrhal  inflammation  of  the  urethral  nuicous 
membrane  in  the  male  and  the  urethral  and  vaginal  mucous  membranes 
in  the  female.  Since  the  discover}^,  by  Neisser,  of  the  gonococcus  which 
goes  by  his  name,  it  has  been  believed  by  many  writers  upon  venereal 
diseases  that  these  bacteria  are  the  cause  of  gonorrhea,  and  that  whei'e 
these  microscopic  bodies  are  absent  the  disease  is  not  gonorrhea,  but 
a  simple  urethritis.  I  am  not  read_y  to  fully  accept  such  a  conclusion, 
as  I  have  seen  instances  in  which  the  gouococci  were  absent  and  yet 
the  disease  ran,  to  all  intents  and  purposes,  the  same  course  precisely 
as  an  ordinary  clap.  I  will,  however,  admit  that,  given  the  presence  of 
the  gonococcus  of  Neisser  in  the  urethral  or  vaginal  discharges,  it  would 
go  far  to  prove  the  existence  of  gonorrlieal  infection  and  that  the  disease 
was  not  simply  catarrhal  in  nature ;  but  the  absence  of  these  gouococci  in 
any  given  specimen  of  the  so-called  gonorrheal  pus  would  not,  I  believe, 
'  autliorize  the  surgeon  to  say  that  the  disease  was  sinq^ly  a  catarrhal 
affection.  The  logical  sequence  of  such  an  opinion  would  l3e  disastrous, 
inasmuch  as  he  would  permit  his  patient  to  have  intercom-se  with  inno- 
cent people,  to  their  detriment.  The  existence  of  these  bodies,  therefore, 
is  of  value  only  when  they  are  present ;  but  the  reverse,  that  is  to  say 
when  they  are  absent,  does  not  prove  that  the  character  of  the  discharge 
is  non-infectious. 

Now  as  to  the  modes  of  infection.  The  time-honored  and  customary 
manner  is  by  cohal)itation  with  a  gonorrheal  person,  be  the  same  nude 
or  female.  But  there  are  other  ways  of  catching  a  clap.  Nearly  all 
surgeons  admit  that  the  leucorrheal  discharge  in  the  female,  apart  from 
the  (juestion  of  gonorrhea,  will  very  frequently  produce  an  irritation  in 
the  male  urethra  which,  call  it  what  you  like,  is,  to  all  intents  and  })ur- 
poses,  a  clap,  and  the  same  is  also  admitted,  Avithin  certain  limits  of  re- 
serve, as  possibly  occurring  from  the  menstrual  discharge  of  a  woman, 
particularly  if  tlie  man  have  connection  with  the  wonuxn  just  before  or 
after  her  flow.  Of  course  every  vaginal  discharge  in  a  woman  is  not 
necessarily  gonorrheal,  and  it  often  beeonu^s  a  nice  question  to  decide 
whether  any  given  secretion  from  a  woman,  which  is  said  to  have  l)een 
the  cause  of  disease  in  the  male,  is  benign  or  otherwise.     If  the  discharge 


506  ^   STSTE2I  OF  LEGAL  MEDICIXE. 

from  the  woman  slionld  be  found  f nil  of  gonococci,  or  if  the  secretion  which 
comes  from  the  vagina  can  also  be  pressed  ont  of  the  nrethra,  the  ver- 
dict wonld  be  rather  against  the  woman,  as  I  know  of  no  disease  except 
gonorrhea  v\'liich  will  produce  a  pni'ulent  discharge  fi*om  the  latter  canal 
in  the  female.  But  if  no  gonococci  are  found  the  woman  shoidd  re- 
ceive the  benefit  of  the  doubt  and  be  considered  as  one  of  those  un- 
happy iDcrsons  whose  vaginal  secretions  are  a  standing  menace  to  every 
male — no,  not  every  male,  because  most  men  become  accustomed  to  the 
vaginal  secretions  of  their  wives  or  mistresses  and  suffer  no  injury,  where 
others  who  poach  upon  forbidden  ground  are  the  worse  for  it.  To  quote 
Eicord's  famous  dictum,  the  husbands  are  "  acclimated." 

Paradoxical  as  it  may  sound,  it  is  possible  for  a  man  to  contract  an 
urethral  discharge  from  a  woman  who  absolutely  shows  no  signs  of 
disease.  The  man  is  the  cause  of  his  own  clap.  Many  men,  after  inter- 
course, are  straightway  filled  with  a  di*ead  of  impending  infection  and 
repair  to  the  di'uggist  for  an  injection  "against  clap."  Tliis  thej^  imme- 
diately use  with  assiduity,  to  find  out,  alas  !  that  things  are  not  what  they 
seem  ;  instead  of  preventing  the  clap,  they  have  iDrought  it  on.  Forth- 
with the  old  cry :  "  The  woman  did  tempt  me ;  "  but  when  the  woman  is 
examined  she  is  found  to  be  entii^ely  sound.  If  the  man  had  waited  to 
find  out  whether  he  really  had  a  clap  he  might  have  escaped  the  necessity 
of  treating  one.  There  is  an  unique  case  given  by  Amedee  Latour  in  a 
footnote  to  Ricord's  Leftres  sur  la  Sypliilis,  p.  51,  in  which  a  clap  was  stated 
to  have  been  caught  without  intercom-se  with  any  female.  Venereal  sur- 
geons are  asked  to  believe  many  curious  statements,  but  I  frankly  declare 
that  if  a  patient  offered  such  a  story  to  me  as  the  ostensible  cause  of  his 
clap  I  should  doubt  him.  The  ease  is  that  of  a  young  man  who,  from 
10  A.M.  to  7  P.M.,  was  engaged  in  the  delectable  occupation  of  attempting 
to  overcome  a  young  woman's  virtue.  She  proved  the  victor  in  the  en- 
counter, and  the  unfortunate  man,  having  suffered  violently  from  priap- 
ism during  the  time  thus  spent,  later  on  nursed  a  severe  clap  which 
lasted  for  forty  days.  He  is  said  to  have  been  continent  for  six  weeks 
pre^dously. 

I  must  mention  one  other  source  of  contagion  which  is  often  pre- 
sented to  the  siu-geon's  attention.  A  man  comes  to  him  and  says  that 
he  has  a  discharge,  which,  upon  examination,  proves  to  be  an  active  and 
healthy  gonorrhea.  The  surgeon  so  informs  him,  when  the  patient 
hastens  to  assure  him  that  it  cannot  be,  for  he  has  had  no  intercourse, 
and  then  with  an  air  of  innocence  inquires  if  it  be  possible  to  catch  it  m 
the  water-closet.  I  know  of  no  better  reply  to  make  than  the  time- 
honored  gag  that  it  is  possible,  but  it  is  a  nasty  place  to  take  a  woman. 
Such  a  plea  the  surgeon  may  listen  to  from  politeness,  but  he  never 
serioush^  entertains  the  idea  that  a  clap  can  be  taken  from  the  water- 
closet  seat,  anj'  more  than  it  can  be  derived  from  a  pair  of  trousers 
borrowed  from  a  friend  "  who  had  a  running,"  which  has  been  gravely 
advanced  to  me  as  the  explanation  for  the  existence  of  a  clap. 

There  is  really  but  one  way  of  catching  it — per  coiium  gonorrlia  fit; 
but  when  we  come  to  speak  of  s^q^hilis  I  shall  show  that  it  is  possible  to 
contract  that  disease  in  other  ways  besides  copulation. 

An  interesting  point  comes  up  as  to  how  far  a  clap  is  contagious  in 
the  male ;  that  is,  up  to  what  stage  in  the  course  of  the  disease  he  is 
capable  of  convejdng  gonorrhea.     Broadly  speaking,  probably  as  long  as 


GENITO-URIXARY  AND    VENEREAL   AEEECTIOXS.  507 

]k'  has  any  (li,s(;liar<>'e ;  most  certainly  as  loii^  as  Ik;  has  auy  purulent 
(lischarj>e,  or  as  long  as  there  are  any  gonococci  to  be  found  in  the 
(liscliarge.  Many  a  man,  after  his  clap  has  lasted  for  several  weeks,  has 
notliing  to  show  except  a  little  mucus  or  a  slightly  pundent  dischai-ge 
in  the  morning.  Dm  ing  the  daytime  nothing  is  ai)parent  and  there 
seems  to  be  no  trouble  whatever.  Sexual  connection,  if  moderately  in- 
dulged ill,  seems  to  produce  very  little  diistnrbiuice.  The  partner  of  his 
amorous  joys  is  free  tVom  disease  until  the  man,  excited  perhaps  with 
wine  or  from  whatever  cause,  overdoes  the  business,  converts  what  was 
a  comparatively  innocuous  discharge  and  mncous  in  character  into  an. 
active  and  purulent  one,  and  then  the  woman  suffers.  It  is  just  suck 
instances  as  this  whicli  make  it  difficult  for  the  surgeon  to  determine 
how  soon  a  man  may  resume  his  m.irital  duties  with  safety  to  his  wife, 
the  i)atient  being  importunate  in  tluit  respect  in  order  to  avert  suspicions 
whicli  perhaps  hav-e  alrc^ady  been  (^xcited  by  his  abstinence  from  his 
duties.  Under  these  circumstances,  it  becomes  exceedingly  difficidt, 
supposing  that  the  wife  contracts  some  disease,  to  be  able  al\va_ys  to 
determine  as  to  whether  its  origin  be  leucorrheal  or  simply  gonorrheal ;. 
first,  because  so  manj^  women  suffer  with  "whites,"  and  secondty,  because 
the  discharge  in  the  patient  may  be  of  the  very  slightest  and  apparently 
mildest  character.  It  is  under  these  conditions  that  the  microscopic 
examination  for  the  gonococci  becomes  of  importance  and  will  go  far 
toward  establishing  the  verdict  against  the  num ;  but  it  sometimes  hap- 
pens that  gonococci  are  not  detected,  and  then  there  is  nothing  left  but 
the  Scotch  verdict  of  '^  non-proven." 

The  results  of  gonorrhea  in  both  male  and  female  play  a  direct  part 
in  the  medico-legal  relations  of  the  sexes  during  marriage.  The  most 
notable  of  these  in  the  male  is  the  inflammation  of  the  epididymes,  which 
produces  blocking  up  and  occlusion  of  the  vasa  defcrentia,  which  lead 
from  the  testes  into  the  urethra,  and  of  which  I  have  already  made  men- 
tion when  speaking  of  sterility  in  the  nuile.  This  inflammation  does  not 
lead  to  any  difference  whatever  in  the  man's  power  or  capacity  for  cojiu- 
lation,  and  so  far  as  his  sexual  strength  is  concerned  neither  he  nor 
his  wife  can  see  any  difference ;  the  only  thing,  perhaps,  which  attracts 
attention  is  that  whereas,  antecedent  to  his  gonorrhea,  he  was  fruitful 
and  capable  of  impregnating  his  wife,  after  his  attack  no  children  are 
born.  This  statement  must,  however,  be  modified  by  the  proviso  that 
for  complete  sterility  to  ensue  the  epididymitis  nuist  have  been  double, 
that  is  to  say,  l)()th  testicles  nuist  liave  been  attacked.  If  one  only  is  at- 
tacked and  the  other  one  is  sound,  the  man  is  sti'll  fruitful,  but  of  course 
he  is  injured  in  so  far  as  he  has  only  one  sound  testicle  instead  of  two. 

I*rostatic  liypei'trophy,  if  it  lie  chronic  and  continuous,  may  produce 
sterility  by  compressing  the  ducts  which  lead  into  the  urethra  from  the 
testes,  but  this  condition  is  m<u-e  likely  to  occur  late  in  life  and  is  asso- 
ciated with  the  chronic  hypertrophy  which  is  met  with  in  elderly  men. 

Inflammation  of  the  vesiculi  seminales,  if  it  has  gone  on  to  su])pura- 
tion  and  destruction  of  ])oth  vesiculi,  will  also  produce  sterility  from 
the  fact  that  the  reservoirs  intended  for  the  reception  of  the  seminal 
fluid  are  no  longer  ])rescnt,  and  there  is  an  obstruction  in  the  course  of 
the  passage  between  the  testes  and  the  urethra ;  l)ut  unless  destructicui  of 
these  organs  occur  the  patient  is  usually  not  much  the  worse  for  his  in- 
flammation. 


508  ^  SYSTEM  OF  LEGAL  MEDICINE. 

Strictures  of  the  urethra,  as  the  result  of  gonorrhea,  I  have  already 
spoken  of,  but  it  is  only  rarely  that  strictures  become  so  extremely  tight 
as  to  cause  regurgitation  of  the  seminal  fluid  into  the  bladder,  instead  of 
anteriorly  through  the  meatus.  When  this  occurs  the  man  is,  to  all  in- 
tents and  purposes,  as  sterile  as  though  his  vasa  deferentia  were  blocked 
and  no  semen  passed  into  the  canal. 

For  the  woman  the  results  of  gonorrhea  may  be  also  disastrous.  I 
by  no  means  share  the  views  of  those  gynecologists  who  consider  that 
every  woman  wlio  has  had  a  clap  is  sterile,  in  consequence  of  inflamma- 
tion of  the  Fallopian  tubes  or  of  the  ovaries ;  but  I  think  there  is  reason- 
able ground  for  believing  that  a  certain  proportion  of  women  are  ren- 
•dered  sterile  in  consequence  of  an  inflammation  of  the  ovaries,  and  in 
those  women  we  oftentimes  find  great  menstrual  disturbance  in  the 
;sha2)e  of  diminished  secretion  of  the  catamenia,  marked  pain  during  the 
menstrnal  molimen,  and  perhaps  the  ejection  of  immature  or  undeveloped 
ova.  I  do  not  believe,  however,  that  clap  ever  produces  as  bad  results 
in  the  woman,  or  that  she  suffers  g^s  severely  as  the  man  in  cases  of 
.gonorrheal  infection. 

Sometimes  gonorrhea  may  produce  so  much  inflammation  as  to  cause 
a  partial  stenosis  of  the  cervical  canal,  which  would  have  an  effect  in  a 
twofold  way — first,  in  preventing  the  natm-al  outfiow  of  the  catamenia, 
and  second,  in  obstructing  the  passage  of  the  spermatozoa  into  the  uterine 
cavity ;  but  this  condition  is  usually  easily  remedied  by  an  operation,  and 
cannot  be  regarded  as  any  serious  derangement  to  the  marital  relations. 

As  regards  the  effect  of  gonorrhea  upon  the  offspring,  it  may  be  said 
to  be  almost  nil.  The  only  way  in  which  the  child  suffers  is  from  a 
form  of  ophthalmia  known  as  ophthalmia  neonatorum ;  but  inasmuch  as 
any  vaginal  discharge  will  produce  the  same  inflammation,  and  inas- 
much as  many  children  acquu-e  an  ophthalmia  from  discharges  entirely 
free  from  suspicion  of  gonorrhea,  the  result  upon  children  need  not 
occupy  attention. 

A  question  here  comes  up  upon  which  the  surgeon  is  not  infrequently 
consulted.  A  man  desires  to  marry,  and  in  the  course  of  his  confessions 
admits  that  he  has  had  repeated  attacks  of  clap  and  still  is  occasionally 
liable  to  some  slight  discharge,  which,  although  not  constant,  is  apt  to 
appear  if  he  over-indulges  in  the  pleasures  of  the  table,  or  drinks  a  little 
more  wine  than  usual,  or  if  he  cohabits  with  a  woman.  This,  the  patient 
assures  the  surgeon,  gives  him  no  imeasiness  physically ;  there  is  no  im- 
pediment to  the  stream  of  urine ;  but  the  patient,  knowing  that  it  is  not 
an  entirely  normal  condition  of  things,  wishes  the  surgeon's  opinion 
before  consummating  his  marriage.  The  surgeon  examines  his  patient 
•carefully  and  finds,  in  the  majority  of  instances,  a  stricture  of  the  ure- 
thra or  granulations  in  the  canal  which  keep  up  more  or  less  iiTitation, 
not  sufficiently  so  to  produce  a  steady  or  constant  discharge,  and  yet 
<?nough,  on  excitation,  to  cause  a  slight  secretion.  He  then  examines 
the  secretion  to  find  if  there  be  any  pus  or  any  of  the  already  mentioned 
gonococci  in  the  discharge.  If  he  finds  these  latter,  as  a  prudent 
surgeon  he  counsels  no  marriage  until  they  disappear,  although  be 
remembers  this  fact,  that  more  women  give  claps  than  get  them.  The 
chance  of  a  woman  being  infected  under  these  circumstances  perhaps 
is  slight,  but  witli  even  tliat  in  the  man's  favor  the  surgeon  has  no  right 
to  counsel  matrimony  until  the  man  is  physically  fit. 


GEXITO-UEIXARY  AND    VEXEUICAL   AFFECTIONS.  500 

But  suppose  lie  finds  no  <j-onoeoeei  and  but  very  little  pus,  what  shall 
he  sayf  jSonie  surgeons  perhaps  might  say  "Marry."  I  think  that  a 
prudent  surgeon  had  better  say  "  Don't,"  beeause  by  gi\'ing-  his  assent  he 
ixssuines  a  tremendous  responsibility.  Suj^pose  any  accident  should  hap- 
pen, although  it  is  quite  likely  that  none  would,  he  would  be  resiJonsible 
for  it ;  therefore  the  best  plan  for  the  surgeon  to  adopt  is  to  recommend 
treatment  until  the  patient  is  entirely  well,  before  giving  his  formal 
consent  to  the  marriage.  In  many  instances,  probably  the  majority  of 
them,  his  advice  will  not  be  followed,  the  mari-iage  will  take  place,  and 
no  accident  happen ;  but  if  any  ill  i-esults  should  follow  he  has  perhajjs 
the  satisfaction  of  knowing  not  only  that  he  had  no  hand  in  Indnging  it 
^bout,  but  had  done  his  best  to  prevent  it.  It  is  Ijetter,  therefore,  to  err 
on  the  side  of  jirudence,  and  to  regard  any  discharge  from  the  urethra, 
unless  it  can  be  clearly  demonstrated  to  be  innocuous,  as  a  possible 
source  of  danger  and  a  bar  to  marriage. 

Syphilis. — We  now  come  to  the  most  important  of  all  diseases  of  a 
venereal  or  sexual  nature :  first,  because  it  is  capable  of  producing  so 
much  mischief  and  misery  in  the  unfortunate  bearers  of  the  disease; 
second,  because  it  is  capable  of  producing  premature  death  or  a  miser- 
able and  unhealthy  life  in  the  unfortunate  offspring  of  the  s^'philitic 
parents ;  and  third,  because  it  can  be  contracted  in  such  unexpected  and 
apparently  innocent  waj^s  that  oftentimes  a  person  who  would  not  wit- 
tingly contaminate  another  is  yet  the  unconscious  instrument  of  spread- 
ing what  may  become  a  horrible  disease.  Of  course  the  commonest  way 
of  contracting  the  disease  is  by  copulation,  but  apart  from  that  method 
it  can  be  conveyed  without  any  improper  or  immoral  conduct  in  either 
the  giver  or  the  receiver.  This  disease  differs  from  all  the  other  venereal 
affections  in  being  constitutional  and  in  the  fact  that  the  secretions  of 
some  of  the  lesions  which  appear  subsequent  to  the  chancre  ^^ill  produce 
the  infection  almost  as  certainly  as  the  chancre  itself.  I  refer  to  the 
mucous  patches  and  to  the  blood  dining  the  earlier  stages  of  syphilis, 
both  of  Avliich  are  capable  of  convepug  the  disease.  Almost  every 
surgeon  has  seen  cases  of  young  women,  innocent  and  \irtuous  in  every 
sense  of  the  Avord,  who  have  been  brought  for  an  opinion  as  to  the 
nature  of  a  pecuhar  lesion  of  the  lip,  the  character  of  which  is  without 
question,  which  has  been  conveyed  through'  the  medium  of  a  perfectly 
innocent  and  proper  kiss  by  men  who  were  the  subject  of  mucous  patches 
of  the  lips  and  tongue,  the  nature  of  which  they  were  ignorant  of,  or 
which,  owing  to  improper  adAdce,  they  conceived  to  be  innocuous  and 
incapable  of  conveying  the  infection.  But  a  short  time  since  a  young 
man  was  sent  to  me  for  consultation  about  the  nature  of  some  peculiar 
lesions  of  the  lips  and  on  the  side  of  the  tongue  which  he  was  inclined 
to  attribute  to  smoking.  He  was  papng  attention  to  a  young  lady,  and 
her  father,  who  was  a  physician,  having  been  consulted  by  this  young 
man  for  these  lesions,  was  suspicious  and  sent  him  to  me  for  my  opinion. 
There  was  no  doubt  as  to  the  character  of  the  lesions,  and  I  so  reported 
to  the  young  man  and  to  the  gentleman  who  sent  him.  The  young  man 
himself  was  much  astonished,  as  he  had  been  continent  for  some  time ; 
but  unfortunately  he  did  not  appreciate  the  fact  that  there  was  a  long 
period  of  incubation  between  the  time  of  the  infection  and  the  appear- 
ance of  the  first  sym])tom — a  period  often  of  thirty  days,  usually,  how- 
lever,  not  so  long.     This  was  an  instance  in  which  trouble  was  averted. 


510  ^   SYSTEM  OF  LEGAL  MEDICINE. 

But  suppose  the  circumstances  had  been  such  that  the  prospective  father- 
in-law,  knowing-  nothing  about  these  things,  and  naturally  being  unsus- 
picious, should  give  his  consent  to  the  engagement.  The  man  would  bo 
accepted  as  the  girl's  suitor,  and  claiming  the  innocent  privilege  of  an 
accepted  lover,  would  convey  by  a  kiss  a  disease  which  might  produce 
untold  misery  and  ill  health  to  his  future  wife,  and  the  sequel  of  im- 
mature and  rotten  abortions  as  offspring.  Under  these  cii'cumstances, 
how  far  would  the  man  himself  be  responsible  for  having  contaminated 
his  fiancee  f  He  might  have  done  it  unwittingly  and  without  any  knowl- 
edge whatever  of  his  disease,  and  yet  the  results  would  be  just  as  bad. 

In  addition  to  the  possibility  of  this  method  of  infection  by  direct 
contact,  there  is  very  good  evidence  to  show  that  it  may  be  contracted 
indh-ectly,  through  the  medium  of  inanimate  things,  such  as  spoons^ 
drinking-cups,  pipes,  and  the  like ;  and  in  factories,  such  as  glass-blowing 
factories,  where  the  blowpipe  is  handed  from  one  workman  to  another 
in  a  gang,  a  syphilitic  subject,  the  bearer  of  mucous  patches,  has  been 
known  to  infect  several  of  Ids  fellow- workmen.  Rollet  gives  an  instance 
in  which  a  woman  was  coutaminated  by  her  cook,  the  mistress  being  in 
the  habit  of  going  downstairs  to  assist  in  the  cooking  and  tasting  of  the 
dishes  with  the  same  spoon  that  the  cook  used,  who,  without  the  knowl- 
edge of  her  unfortunate  mistress,  was  the  possessor  of  mucous  patches 
of  the  mouth. 

Again,  in  former  days,  when  vaccination  was  practiced  from  arm  to 
arm  and  when  as  much  care  was  not  exercised  as  at  present,  the  scab  or 
crust  taken  from  the  syphilitic  baby  or  person  has  been  the  means  of 
infecting  an  entii*e  community,  and  the  mischief,  being  started,  was  con- 
tinued in  various  ways,  by  the  contamination  from  the  babies'  lips  to 
women  suckling  them,  and  from  these  women  to  their  husbands  or  to 
their  own  babies,  until,  in  tliis  community  of  which  I  write  (in  Italy), 
the  infectiou  spread  through  the  entire  village  and  there  were  very  few 
of  the  inhabitants  but  showed  some  manifestations  of  syphilis. 

Nor  are  the  symptoms  in  the  acquired  form  the  only  ones  which  are  con- 
tagious. In  the  congenital  variety  the  mucous  patches  of  the  baby,  notably 
of  its  mouth,  are  capable  of  conveying  the  disease  to  those  persons  about 
it  who  are  free  from  syphihs,  either  by  the  process  of  suckling  or  by  kiss- 
ing ;  and  nurses  are  not  infrequently  contaminated  by  giving  the  breast 
to  children  who  may  be,  to  all  outward  appearances,  fairly  healthy,  and 
yet  be  syphilitic.  In  some  instances  the  syjDhilitic  baby  is  born  appar- 
ently healthy,  fairly  well  noui'ished,  a.nd  free  from  any  sign  of  syphilis. 
Shortly  after  birth  manifestations  of  the  disease  appear  upon  it  which, 
although  not  apparent  to  the  uupracticed  eye,  are  highly  contagious  and 
capal)le  of  infecting  sound  persons.  Now  in  cases  where  both  baby  and 
nurse  are  undoubtedly  syphilitic,  the  question  often  arises  whether  the 
baby  has  been  the  cause  of  the  nurse's  infection  or  whether  the  nurse 
has  given  the  child  the  disease.  The  st(n-y  usually  told  the  surgeon  is  as 
follows :  That  the  baby,  apparently  well  at  first,  was  put  to  the  nurse's- 
breast ;  that  it  gradually  lost  health  and  strength,  and  became,  from  a 
healthy  child,  a  weak,  puny,  miserable  brat.  The  nurse  then  exposes  to 
the  surgeon  a  breast  the  nipple  of  which  is  fissured  and  cracked,  perhaps 
bearing  upon  its  surface  an  ulceration,  seated  upon  a  raised  base,  in- 
durated; and  showing  glandular  indurations  in  the  axilla.  The  nurse 
accuses  the  child  of  giving,  her  the  disease,  the  parents,  on  the  other 


GENITO-UIUXAnV  AND    yjCXEREAL  AFFECTIONS.  511 

luind,  accuse  tlic  nnrso,  and  the  surgeon  is  called  in  to  settle  the  question. 
The  first  g-lance  tells  hini  that  the  baby  is  the  probahle  sounre  of  the 
trouble,  for  the  reason  that  all  cases  of  syphilis  in  wliich  the  disease  is 
acquired,  whether  in  the  tulult  or  in  the  infant,  begin  "vvilli  an  initial 
lesion  (cliancre) ;  the  onh^  variety  which  is  devoid  of  initial  lesions,  so 
far  as  known,  is  the  congenital  form.  Mucous  patches  belong  to  a 
subsequent  stage  and  do  not  appear  until  after  a  period  of  incubation 
varying  from  six  to  ten  weeks.  If,  therefore,  the  nurse  had  been  the 
source  of  the  syphilis  of  the  child,  it  is  the  child  who  should  show  an 
initial  lesion  and  not  the  nurse.  In  addition,  the  nurse  would  probahly 
show  some  eruption  on  the  bod^',  general  induration  of  the  glands  all 
over  the  body,  nnicous  patches  of  the  mouth  and  elsewhere — in  short, 
the  usual  synq^toms  of  the  so-called  secondary  stage,  or  the  stage  which 
follows  the  outbreak  of  the  initial  lesion.  But  instead  of  that  it  is  the 
bab}'  who  shows  these  symptoms,  symptoms  which  occur  at  a  period 
later  than  the  nurse's  lesion,  and  which  she,  in  turn,  will  show  as  the 
disease  progresses  in  her.  It  is  therefore  the  baby  which  is  at  fault  and 
not  the  nurse,  and  it  is  important  for  the  surgeon  in  all  cases  of  sj-philis- 
to  bear  in  mind  the  question  of  dates  and  what  lesions  are  likely  to  occur 
in  regular  sequence ;  for  unless  these  points  are  well  borne  in  mind,  error 
and  confusion  are  apt  to  ensue. 

Then,  again,  the  baby  may  show  other  symptoms  of  disease  which 
would  prove  it  to  be  of  congenital  origin,  such  as  the  bullaB  of  pemphi- 
gus, with  maceration  and  desquamation  of  the  skin,  these  two  latter 
being  almost  pathognomonic  of  congenital  syphilis.  It  would  also  pre- 
sent the  evidence  of  trouble  in  its  throat,  the  hoarse,  squeaking  ciy, 
the  presence  of  ulcerations  in  the  interior  of  the  mouth,  with  fissures  of 
the  lips,  and  the  emaciated,  puny,  weazened  look  which  S}q3hilitic  babies 
show  when  profoundly  poisoned.  Under  such  conditions,  when  it  is 
clearly  the  child  which  is  at  fault,  it  is  the  duty  of  the  sui-geon,  when  he 
is  obliged  to  call  in  a  wet-nurse  for  a  s\q3hilitic  baby,  to  inform  the  pro- 
spective foster-mother  of  the  child's  condition.  No  matter  what  his  rela- 
tions to  the  parents  may  be,  no  surgeon  should  ever  kno\\dngly  permit 
himself  to  be  made  the  means  of  conveying  the  disease  from  the  baby  to 
the  healthy  woman,  whose  health  is  often  the  only  tiling  she  has  to  rely 
upon  for  a  livelihood ;  it  is  far  better  that  such  a  baby  should  die  than 
that  an}^  woman  should  be  exposed  to  the  slightest  risk  so  far  as  syphilis 
is  concerned. 

But  notwithstanding  all  admonition,  it  is  exceedingly  difficult  to  im- 
press people  ■with  the  danger  and  the  risk  tliat  they  run  in  playing  with 
or  in  fondling  syphilitic  childi-en.  Many  women  and  guls  are  singularly 
fond  of  kissing  every  baby  they  come  across,  without  taking  into  the 
slightest  consideration  the  possibiUty  of  the  child  being  diseased,  and 
the  only  wonder  is  that  more  mischief  does  not  ensue  from  this  indis- 
criminate fondling  of  children.  I  recall  one  instance  in  which  a  small 
bo}',  three  years  of  age,  was  sent  to  me  for  a  diagnosis.  This,  oddly 
enough,  was  a  case  of  acquired  syphilis,  the  initial  lesion  (chancre)  being 
seated  on  the  inside  of  the  lower  eyelid.  How  the  boy  got  it  I  never 
could  find  out.  His  father  and  mother  and  his  immediate  relations 
denied  having  the  disease  (the  immediate  relations  consisted  of  his  father 
and  mother  and  a  young  aunt).  The  father  and  mother  I  examined,  and 
could  find  nothing  the  matter  with  them ;  the  j'oung  aunt  I  did  not  see ; 


512  -4   SYSTEM  OF  LEGAL  MEDICINE. 

bnt  at  any  rate  the  fact  existed — tlie  boy  had  acquired  syphilis.  When 
the  time  arrived  for  subsequent  lesions  to  make  their  appearance  I  cau- 
tioned the  mother  that  all  the  family  were  in  possible  danger  of  con- 
tracting the  disease.  Inasmuch  as  it  was  not  a  congenital  disease,  she 
was  just  as  much  exposed  to  danger  as  the  rest,  and  I  particularly  cau- 
tioned her  not  to  let  liim  play  with  or  kiss  his  little  sister,  a  girl  between 
five  and  six  years  of  age,  who  was  very  fond  of  him,  and,  like  all  little 
sisters,  played  with  and  kissed  her  baby  brother.  I  thought  I  had  im- 
pressed upon  her  mind  the  importance  of  my  advice,  when,  to  vaj  aston- 
ishment, a  few  weeks  later  she  brought  the  girl  to  see  me  with  a  beauti- 
ful chancre  on  the  cheek,  and  the  histor}^  was  that  the  child  had  a  httle 
scratch  on  the  cheek,  they  were  allowed  to  play  together  as  the}^  formerly 
had  been,  the  httle  boy  had  probably  kissed  his  sister  there,  and  the 
result  was  a  fine  chancre  of  the  cheek.  Both  of  them  went  through  the 
subsequent  lesions  of  syjDhihs,  the  boy  slightly,  the  girl  more  severely. 

The  question  may  arise,  How  far  are  the  symptoms  of  syphihs  conta- 
gious "?  or,  in  other  words.  Is  syphihs  during  its  entire  duration  capable 
of  being  inoculated  from  one  person  to  another  ?  It  is  one  of  the  pecu- 
liarities of  this  disease  that  the  physiological  secretions,  the  tears,  the 
•sweat,  the  milk,  are  incapable  of  conveying  the  disease,  even  though 
they  be  directly  inoculated  upon  healthy  people.  The  only  exception 
which  has  been  claimed  to  the  rule  that  syphihs  is  not  communicable 
through  a  physiological  secretion  is  in  the  supposed  cases  of  the  infection 
of  the  wife  by  the  semen.  I  am  myself  a  disbeliever  in  this  method  of 
conveying  syphilis,  but  for  the  information  of  my  readers  let  me  explain 
in  a  few  words  what  the  supposed  modus  operandi  of  infection  is  in  these 
cases. 

A  previously  syphihtic  man  marries  a  healthy  woman,  who  remains 
seemingly  healthy  throughout  her  married  life,  provided  no  children  are 
born.  Suppose  the  woman  becomes  pregnant :  straightway  she  begins  to 
show  symptoms  of  the  disease.  The  baby,  in  due  course  of  time,  comes 
into  the  world  with  manifest  •syphilitic  lesions.  Query — How  did  the 
woman  get  her  syphihs"?  The  behevers  in  the  indirect  method  claim 
that  the  semen  of  the  father  is  capable  of  conveying  the  disease  through 
the  ovum,  which,  becoming  infected,  is  the  focus  of  infection  for  the 
mother,  who,  contracting  it  through  the  uterine  and  placental  vessels,  for 
the  first  time  becomes  inoculated.  This  is  what  Ricord  calls  infection 
from  clioc  en  refour.  The  father  himself  may  show  no  symptoms  what- 
•ever  of  the  disease,  nor  perhaps  has  he  during  his  entire  married  life, 
and  yet  both  mother  and  child  are  palpably  syphilitic.  There  is  nothing 
harder  in  the  practice  of  venereal  medicine  than  to  establish  the  origin 
of  such  a  woman's  syphihs.  Women  often  acquire  syphilis  in  a  most 
mysterious  manner,  and  of  course,  unless  absolutely  obliged  to,  they 
seldom  will  confess  even  to  then-  medical  attendant  the  fact  that  they 
have  ever  had  the  disease.  Many  of  them  in  perfectly  good  faith  mislead 
the  attending  surgeon  by  positively  declaring  that  they  have  never  been 
exposed  to  contagion,  and  yet  instances  are  not  wanting  where  women 
have  had  the  disease  previous  to  marriage,  have  apparently  entirely 
recovered  from  it,  and  show  no  subsequent  evidences  ^f  their  former 
syphihs,  even  at  the  time  of  the  child's  bh'th.  A  notable  and  most  curious 
instance  of  this  kind  has  been  narrated  by  Dr.  Keyes  ( Venereal  Diseases, 
13.  71),  in  which  a  lady  was  under  his  care  for  a  very  mild  and  trifling 


GENITO-URINARY  AND    VENEREAL   AFFICCrWNS.  513 

syphilis,  appni-ontly  not  conti-aotod  from  hor  liushand.  Like  most  womon, 
she  Wiis  careless  in  pursuing  treatment  and  seeniin<;']y  entirely  recovered. 
About  that  time  she  gave  birth  to  a  syphilitic  child,  which  died.  The 
father  Ixicame  syphilitic,  and  in  the  report  of  the  case  it  is  stated  that  the 
father's  syphilis  was  claimed  to  have  been  deiived  from  the  child,  who 
was  said  to  have  })een  ])oisoned  by  its  wet-nurse.  Matters  went  oji  in 
this  way  for  some  time  until  the  woman  became  again  ])regnaiit  in  an- 
other city.  She  gave  birth  to  an  apparently  healthy  child,  who  was  ])ut 
by  the  attending  physician  under  the  care;  of  a  wet-nurse.  The  mirse 
shortly  ac([uired  a  sore  upon  lier  nip})le  which  turned  out  to  be  sy])hilis, 
and  the  baby  also  presented  evidences  of  the  same  disease.  The  mu'se 
was  accused  of  having  poisoned  the  child  with  syphilis  and  was  dis- 
charged. The  child  was  put  under  treatment,  another  nurse  was  ol)- 
tained  for  it,  and  in  due  course  of  time  this  second  nurse  also  developed 
a  chancre  on  the  nipple.  The  family  shortly  before  that  had  retui'ued 
to  New  York,  and  came  again  under  the  care  of  Dr.  Keyes.  The  mother 
seemed  to  be  perfectly  well  and  presented  no  traces  of  sj^^ihilis;  the 
father,  on  the  other  hand,  still  showed  evidences  of  the  disease.  A  third 
pregnancy  followed ;  the  woman  still  remained  apparently  perfectly  well, 
and,  although  advised  to  follow  treatment,  neglected  to  do  so.  A  still- 
born child  was  the  result,  which  apparently  had  been  dead  for  some 
time.     The  mother  still  showed  no  evidences  of  the  disease. 

Here  is  an  instance  where,  if  Dr.  Keyes  had  not  had  the  opportunity 
of  seeing  the  woman  in  the  early  stage  when  she  had  the  symi)toms  of 
her  syphilis — mild,  it  is  true — he  would  very  easily  have  been  misled 
into  considering  this  as  an  instance  oi  infedio  per  patris  seminem.  But 
besides  that,  it  shows  that  a  woman  maj'  for  years  enjoy  good  health, 
showing  no  evidence  of  the  fact  that  she  has  been  sypliihtic,  and  still 
she  can  give  birth  during  that  time  to  S3'philitic  children. 

Grefsberg  ( Vierteljahresschrift  fur  Dermatohgie,  1879,  p.  102)  gives  a 
case  of  a  woman  who  for  two  years  suffered  from  syphilis,  from  wMcli  she 
apparently  i-ecovered.  A  year  after  recovery  and  three  years  after  her 
attack  she  mai-ried  a  man  who  was  not  syphilitic,  and  in  ten  ye-Avs  of 
married  life  she  had  eleven  ndscarriages.  At  the  twelfth  pregnancy, 
thirteen  and  a  half  years  after  the  initial  lesion,  she  went  to  full  tei-m 
and  was  delivered  of  a  syphilitic  child.  In  this  instance  the  period  of 
apparent  immunity  was  even  longer  than  in  that  of  Dr.  Keyes,  being 
practically  eleven  years  in  which  the  woman  had  seen  no  evidence  of 
the  syphilis,  and  yet  there  is  no  reason  to  doubt  that  her  offspring  were 
diseased  or  that  the  abortions  which  she  had  were  due  to  her  old 
trouble.  It  will  be  noted  in  this  case  that  the  father  claims  never  to 
have  contracted  sjq^hilis. 

In  the  course  of  syphilis  there  are  many  periods,  varying  from  a  few 
weeks  to  many  months,  in  which  there  is  an  entire  absence  of  any  syphi- 
litic lesions — there  is  a  lull  in  the  activity  of  the  disease.  The  patient  is 
outwardly  well,  and,  indeed,  so  far  as  can  be  told  by  any  examination 
whaetver,  is  well ;  and  yet  this  seeming  immunity  is  no  guaranty  that 
syphilis  will  not  crop  out  in  the  children.  INIany  cases  are  found  in 
vener(^al  litei-ature  in  suppoi't  of  this  proposition. 

Tlu^  question  might  arise  whether  such  a  condition  of  affairs  Avould 
be  sufficient  ground  for  a  divorce.  That  aspect  of  the  case,  (^f  course. 
I  have  nothing  to  do  mth,  and  I  instance  these  cases  merely  to  illustrate 


514  ^   SYSTEM  OF  LEGAL  MEDLCINE. 

the  importance  of  the  surgeon  being  upon  his  guard,  when  he  is  called 
upon  for  an  opinion  in  eases  of  apparent  immunity  on  the  woman's  side 
from  syphilis,  not  to  make  too  hasty  a  judgment  that  because  nothing 
is  apparent  there  is  no  danger  of  syphilis — a  reversal  of  the  adage  that 
as  to  those  things  which  are  not  apparent  and  those  things  which  do  not 
exist,  the  reasoning  is  the  same. 

Is  there  no  way  in  which  the  surgeon  can  tell  ?  I  know  none  in  which 
the  point  can  be  decided  positively,  but  it  may  be  decided  inferentially 
in  this  manner :  Continued  and  repeated  abortions  should  always  excite 
suspicion  of  syphUis,  no  matter  who  the  parties  may  be.  Syphihs  is  no 
respecter  of  persons,  and,  hke  the  pale  Death  of  the  poet,  invades  both 
the  palace  of  the  rich  and  the  cabin  of  the  poor ;  so  that  where  repeated 
miscarriages  take  place,  the  surgeon  should  bear  in- mind  that  one  of  the 
likeliest  causes  of  the  trouble  is  syphilis.  Of  com'se,  with  regard  to 
histories,  if  neither  man  nor  woman  present  any  evidence  of  disease,  it 
is  hopeless  to  expect  to  get  anything  definite,  and  an  examination  of 
either  one  or  both  of  them  may  end  perfectly  negatively,  because  a  per- 
son can  have  had  a  mild  form  of  syphilis,  recover  entirely  from  it,  and 
present  no  evidences  as  to  its  previous  existence. 

There  is  one  peculiar  point — a  curious  fact,  known  as  Colles's  law — 
which  is  that  the  seemingly  non-syphilitic  mother  cannot  be  infected  by 
her  syphilitic  child  extra  uterum.  The  child  may  be  a  source  of  danger 
to  everybody  else  around  it  who  has  not  been  protected  by  a  previous 
attack  of  syphihs,  but  the  mother  may  kiss  her  diseased  offspring,  suckle 
it,  and  permit  the  most  intimate  relations,  without  suffering  in  the  shght- 
est  degree.  And  another  singular  thing  is  that  such  a  woman  is  exempt 
from  any  attempt  to  inoculate  her  with  the  contagious  secretions  of 
syphihs.  Such  has  been  tried  by  Caspary  of  Berhn  ( Vierteljaliressclirift 
fur  Bermatologie,  1875,  p.  437),  with  a  negative  result. 

Another  of  the  singular  features  about  syi)hihs  is  that  the  disease 
does  not  pursue  a  continuous  course ;  the  appearances  of  the  lesions  are 
interrupted  by  periods  when  the  patient  feels  and  is  j)i"actically  as  well 
as  he  ever  was.  These  intervals  are  called  the  periods  of  repose.  Sup- 
pose a  man  were  to  marry  in  this  interval,  when  all  symptoms  were 
absent,  when  he  beheved  himself  in  good  faith  to  be  entirely  well,  how 
far  would  the  appearance  of  sulisequent  sjnnptoms  later  on  be  a  ground 
for  marital  separation  ?  And  again,  suppose  that  in  this  interval  of  re- 
pose a  man  engages  himself  to  a  woman,  and  before  the  marriage  takes 
place  finds  that  he  is  not  entirely  well  and  that  symptoms  of  the  disease 
are  presenting  themselves,  how  far  would  such  a  man  be  justified  in 
breaking  his  engagement?  I  know  of  no  eases  bearing  upon  the  first 
13oint,  but  on  the  second  a  case  recently  occurred  which  was  tried  in 
Kentucky  and  was  finally  decided  in  the  Court  of  Appeals  of  that  State 
in  favor  of  the  defendant,  who  was  a  man.  The  cu-cumstances,  as  nar- 
rated to  me  by  the  physician  who  attended  the  man,  were  these :  X  con- 
tracted syphilis,  from  which  he  beheved  he  was  entirely  well,  and  in 
this  period  of  apparent  recovery  engaged  himself  to  a  young  woman. 
Before  the  marriage  took  place  he  broke  out  with,  later  symj^toms  of  the 
disease,  and,  under  the  circumstances,  broke  off  his  engagement  to  the 
young  woman,  explaining,  as  I  understand,  to  her  lawyer  the  condition 
of  affairs.  The  statement  was  not  accepted  and  a  suit  followed.  After 
being  tried  in  the  minor  courts  it  went  to  the  Com-t  of  Appeals  in  Ken- 


GENITO-URINAET  AND    VENEREAL  AFFECTIONS.  515 

tiieliy  and  was  dooided  in  the  man's  favor  on  the  ground  tliat,  although 
at  the  time  of  his  en^'ao'ement  he  lionestly  l)eheved  himself  to  ))e  well,  on 
finding-  out  his  mistake  later  on,  as  an  honorable  man,  rather  than  bring 
misery  upon  his  future  wife,  he  decided  to  break  the  engagemtmt.  The 
plaintiif's  side  attempted  to  show  that  the  mere  fact  <jf  his  having  these 
late  lesions  was  no  bar  to  his  marriage,  because  they  were  probably  not 
infectious,  and  quoted  various  authorities  to  show  why  the  man  should 
have  carried  out  his  contract ;  but  the  coiu't  decided  otherwise,  stating 
that,  as  long  as  there  was  a  question,  the  man  was  justified  in  breaking 
off  his  engagement* 

A  syphilitic  patient,  having  run  through  the  earlier  manifestations  of 
his  disease,  marries  during  an  interval  of  repose,  or  during  a  period  in 
the  course  of  his  disease  when  he  believes  himself  to  be  perfectly  well, 
and  later  on  during  the  ccmrse  of  his  married  life  shows  symptoms  of 
late  or  so-called  tertiary  syphilis.  The  question  then  arises  whether  there 
is  an}^  Hkelihood  of  these  lesions  proving  contagious  and  capable  of  in- 
fecting either  the  wife  or  future  children.  The  general  opinion  among 
venereal  surgeons  is  that  the  late  stages — so-called  tertiary  stages — of 
syphilis  are  not  contagious  nor  capable  of  communicating  the  disease,  and 
yet  the  surgeon  may  be  confronted  with  cases  which  will  put  his  belief 
to  a  severe  test  and  may  perhaps  induce  him  to  change  his  opinion  as  to 
the  non-inoculability  of  the  late  lesions  of  syphilis.  The  difficulties  in 
such  a  case  as  this  are  so  very  well  exemplified  in  a  case  which  is  given 
by  Dr.  F.  N.  Otis  {Clinical  Lectures  on  Physiological  Pathology,  and  Treat- 
mod  of  Syphilis,  p.  107)  that  it  may  serve  as  an  example,  in  the  fii'st  place, 
of  the  difficulty  in  obtaining  testimonj^,  and,  in  the  second  place,  of  the 
danger  of  making  up  an  opinion  hurriedly  and  in  the  face  of  what  would 
appear,  perhcips,  good  evidence.  The  case  was  that  of  a  young  man  who 
was  under  Dr.  Otis's  care  for  early  syphilis,  and  after  ti-eatment  appar- 
ently recovered  entirel}^  from  his  disease.  The  treatment  was  continued 
for  about  two  years,  and  at  the  end  of  that  time  the  patient,  believing  him- 
self well,  married.  The  wife  gave  bii'th  to  a  child  which  was  perfectly 
healthy  and  remained  so  up  to  its  third  year,  when  he  died  of  tubercular 
meningitis,  following  scarlet  fever,  there  not  being  then  or  pre\dou.sly 
any  manifestations  of  syphilis.  Later  on  the  patient  had  a  gummous 
j)eriostitis  of  his  right  til)ia,  for  which  he  was  treated  and  which  disap- 
peared entirely  within  a  mouth.  From  that  time,  for  nearly  a  year,  both 
husband  and  wife  were  healthy,  Avhen  one  morning  the  husband  came 
to  announce  that  his  ^\afe  had  trouble  in  her  moiith  which  looked  like 
what  he  had  had  during  his  early  syphilis.  Dr.  Otis  doubted  if  it 
was  syphilis,  because  the  "VNofe's  character  was  above  suspicion,  and  he 
did  not  believe  that  the  late  lesions  of  syphihs  could  convey  the  disease. 
The  woman  was  sent  to  see  him,  and,  to  his  utter  astonishment,  he  found 
that  she  had  syphilis,  as  was  shown  by  miicous  patches  in  her  nu^uth, 
together  with  mucous  tubercles  on  the  inner  border  of  the  thigh  and  the 
right  labium  ma  jus. 

Here  was  the  question  :  Was  Dr.  Otis  MTong  ?  Can  syphilis  be  con- 
veyed by  the  late  lesions  ?  Or  was  Dr.  Otis  right  ?  and  if  so,  then  the 
woman  contracted  her  sj'phihs  from  some  one  who  had  a  recent  s^'pliilis, 

*  Shacl-Jeford  vs.  Hamilton.  The  Soiitliw-esteru  Reporter,  Vol.  19,  Xo.  1,  May  2, 
1892,  p.  5. 


516  A   SYSTEM  OF  LEGAL  MEDICINE. 

evidently  not  her  husband.  The  husband  was  allowed  to  believe  that  he 
was  the  source  of  the  trouble,  but  the  doctor  kept  his  own  counsel  and 
at  the  right  time  asking  permission  of  the  husband  to  tell  the  wife  what 
the  matter  was  with  her,  after  a  httle  fencing  and  hard  pushing,  got  from 
her  a  confession  that  a  yachting  excursion,  an  unexpected  night  at  sea, 
exposure  with  an  old  lover  three  months  before  her  outbreak,  were  the 
causes  of  her  trouble ;  and  the  truth  of  this  was  substantiated  bya  letter 
received  from  the  source  of  the  trouble,  stating  that  he  had  discovered 
hhnself  to  be  syphihtic,  expressing  great  regret,  and  inquiring  if  she  had 
been  lucky  enough  to  have  escaped  the  infection.  I  think  the  case  hardly 
needs  comment ;  it  is  peculiarl}^  instructive  and  only  shows  how  necessary 
it  is  for  the  surgeon,  even  at  the  risk  of  being  considered  cynical  and 
suspicious,  to  suspect  everybody  connected  with  a  case  of  syphilis, 
particularly  if  the  history  of  the  case  requires  acceptance  of  what  is- 
highly  improbable  or  what  is  not  in  accordance  with  our  present  knowl- 
edge of  the  disease.  The  surgeon,  of  course,  should  not  be  dogmatic  in 
his  opinion  5  he  should  always  remember  that  it  is  the  unexpected  that 
happens ;  but,  on  the  other  hand,  he  should  carefully  consider  the  fact 
that  syphihs  is  a  disease  full  of  most  unpleasant  surprises,  and  that  vene- 
real patients,  particularly  when  it  comes  to  a  question  of  expert  employ- 
ment, will  tell  the  most  unconscionable  and  unblushing  falsehoods,  and 
perhaps  not  unnaturally,  for  the  reason  that  no  person  is  bound  to  crimi- 
nate himself,  and  it  is  for  the  doctor  to  find  out  how  far  they  are  telhng 
the  truth ;  and,  though  perhaps  it  may  sound  bitter,  the  surgeon  should 
further  remember  that  people  who  come  into  court  with  their  venereal 
or  sexual  troubles  have  usually  said  good-by  to  both  their  reputation  and 
to  their  capacity  for  truth-telling. 


MARRIAGE   AND   DIVORCE. 

BY 

SIMEON  E.    BALD^VIX,    LL.D. 
JMAERIAGE. 

Definition  of  Marriage — Scope  of  this  Article. — Maraage  is  a  con- 
tract between  persons  of  a  different  sex  for  cohabitation  as  man  and 
wife,  clm-ing  their  joint  lives,  whereby  a  new  social  relation  is  created 
between  them,  and  a  new  legal  status  acquired  by  the  woman.  It  is  an 
institution  of  society  in  which  the  whole  community  have  an  interest, 
and  which  is  everywhere  regulated  to  some  extent  by  positive  law. 

It  is  the  object  of  this  article  to  treat  of  marriage  and  its  dissolution 
solely  mth  reference  to  such  points  as  may  be  of  common  interest  both 
to  the  physician  and  the  lawyer. 

Statutory  Regulation. — Each  of  the  United  States  has  its  own  law 
upon  this  subject,  as  to  marriages  contracted  within  its  jm-isdiction,  or 
with  a  view  to  future  residence  there,  though  contracted  elsewhere. 

The  United  States,  as  such,  have  no  law  as  to  marriage  which  is  oper- 
ative Avithiu  any  State.  Congress  has  made  regulations  with  reference 
to  those  celebrated  in  the  District  of  Columbia,  in  the  several  Territories 
of  the  United  States,  and  abroad.  Those  of  the  latter  class  can  be  entered 
into  between  any  persons  who  would  be  competent  to  many  if  residing 
in  the  District  of  Columbia,  before  any  Consular  officer  of  the  United 
States  in  any  foreign  country. 

By  an  act  of  Congress  passed  in  1887,  marriage  is  prohibited  in  any 
of  the  Territories  between  persons  related  within  and  not  including  the 
fourth  degree  of  consanguinity,  computed  according  to  the  rules  of  the 
ci\'il  law  (of  the  old  Roman  Empu-e).  Bigamy  and  polygamy  are  also 
prohibited  in  the  Territories. 

Age  of  Consent. — The  age  which  must  have  been  attained  by  the 
parties  to  a  marriage  is  in  most  of  the  older  States  (following  both  the 
civil  and  the  common  law)  fourteen  for  males  and  twelve  for  females. 
In  the  Middle  and  many  of  the  Western  States  it  is  higher ;  often  eight- 
een for  males  and  fourteen  for  females;  in  some  cases  sixteen  for 
females.* 

Marriages  of  those  under  the  prescribed  age  can  be  disaffirmed  by 
either  as  soon  as  it  is  reached,  or  annidled  by  the  courts  prior  to  tluit 
time.     It  is  of  no  importance  whether  the  parties  were  or  were  not,  when 

*  Vifle  Indecent  Assault  Upon  Cliildven,  vol.  i.,  and  Rape,  vol.  ii. 

517 


518  -4  SYSTEM  OF  LEGAL  MEDICIXE. 

manied,  phYsicaUy  capalale  of  sexual  intercoiu'se.  If  they  or  eitlier  of 
them  were  not  of  the  legal  age  for  cousent  the  marriage  can  be  set  aside. 

Capacity  to  Consent — Insanity. — The  parties  to  the  mari'iage  con- 
tract must  not  only  he  of  sufficient  age,  but  of  sufficient  mental  capac- 
ity, in  fact,  to  understand  the  general  nature  and  consequences  of  the  act. 

Insanity  or  idiocy  at  the  time  of  marriage  is  ahvays  and  everywhere 
a  legal  impediment.  Supervenient  insanity  was  not  a  cause  of  divorce 
at  common  law,  nor  is  it  one  mider  the  statutes  of  most  of  our  States. 
It  is  occasionally  made  the  gTound  of  a  special  act  of  divorce,  granted 
by  the  legislature ;  but  such  a  power  is  not  vested  in  the  legislatui-es  of 
all  the  States.  It  does  generally  belong  to  the  Territorial  legislatures, 
under  the  laws  of  the  United  States. 

Monomania  or  delusions,  which  do  not  disqualify  a  person  for  enter- 
ing into  the  general  transactions  of  life,  and  managing  his  affau's  mth 
ordinary  prudence  and  skill,  and  do  not  affect  his  understanding  of  the 
marriage  contract,  or  his  ability  to  perform  its  obligations,  will  not  de- 
feat its  vahdit^'. 

Seated  insanit\^  defeats  a  marriage  with  the  insane  person,  although 
it  was  celebrated  dui-ing  a  lucid  inter^-al.  On  the  other  hand,  a  sane 
person  may  avoid  a  maniage  contracted  dining  temporary  insanity,  even 
if  produced  by  drunkenness.  A  marriage  contracted  while  insane  may 
be  confirmed  by  the  party  whose  mind  was  so  affected,  should  he  regain 
his  reason,  and  such  confii'mation  may  be  estabhshed  by  continued  co- 
habitation. In  such  a  case  no  new  celebration  of  the  marriage  is  neces- 
sary.    The  original  maniage  will  be  treated  as  voidable,  not  void.* 

Capacity  to  Consummate  the  Marriage. — Although  the  parties 
have  reached  the  proper  age  and  are  of  sufficient  mental  capacity,  they 
cannot  many  unless  physically  capable  of  sexual  intercoui'se.  This  does 
not  mean  that  the  man  must  be  able  to  beget  cliildren  and  the  woman 
to  conceive  and  bear  them.  It  is  enough  3  the  physical  condition  of 
each  at  the  time  of  marriage  is  such  as  to  fuLfiU  the  conditions  of  copu- 
lation, though  not  of  procreation.!  This  much  each  party  may  insist 
upon,  as  essential  to  the  validity  of  the  marriage,  notT\ithstaiiding  the 
woman  was,  at  the  time  of  its  celebration,  beyond  the  age  of  child-bear- 
ing. The  right,  however,  is  one  which  may  be  waived,  and  is  waived 
when  maniage  is  knowingly  contracted  mth  an  impotent  person,  or  one 
of  so  advanced  an  age  that  impotence  might  naturally  be  exj)ected  to 
exist. 

Impotence,  as  above  explained,  while  a  cause  of  divorce  in  all  our 
States,  does  not  in  most  of  them  render  the  marriage  absolutely  void 
from  the  beginning.  If  it  is  due  to  a  temporary  cause,  and  is  curable, 
it  is  no  legal  impediment  to  the  maniage,  unless  after  marriage  the  party 
refuses  to  submit,  Avithin  a  reasonable  time,  to  the  proper  treatment  for 
its  removal. 

A  refusal  on  the  part  of  either  to  participate  in  sexual  intercourse, 
AAithin  a  reasonable  time  after  maniage,  if  unexplained,  raises  a  presump- 
tion of  incapacity. 

If,  while  sexual  intercourse  is  not  physically  impossible,  it  is  practic- 
ally so,  because  possible  only  under  conditions  to  which  the  other  party 

*  Cole  vs.  Cole,  5  Sneed's  Tenn.  Eep.  57 ;  70  Am.  Dec.  275. 

t  Schotder  on  Hu^hand  and  Wife,  §  23 ;  J.  G.  vs.  B.  G.,  33  Ind.  Eep.  401. 


MAUniACK   AM)    DIVORCE.  519 

ought  not  to  l)e  expected  to  submit,  the  case  would  be  one  of  legal  im- 
potence, t'urnisliiiig  a  sufficient  ground  for  divorce. 

Impotence  is,  in  some  States,  made  a  (?ause  of  divorce  on  the  ground 
•of  a  fraud  in  inducing  the  petitioner  to  contract  the  marriage.  It  is 
generally  rested,  liowever,  on  the  foundation  of  the  want  of  capacity  to 
conclude  the  contract ;  nor  is  the  ignorance  of  the  impotent  party  that 
impotence  exists  anywhere  received  as  a  defense.  If,  however,  impotence 
exists,  and  is  known  to  the  party  disa])led  by  it,  it  may  be  an  actual  fraud 
in  such  party  to  contract  marriage  without  disclosing  the  fact  to  the 
-other  party.  Thus,  if  a  woman,  while  of  an  age  for  child-bearing,  should 
be  rendered  barren  l)y  sul)mitting  to  the  operation  of  ovariotomy,  it 
would  be  a  fraud  on  her  part  not  to  disclose  the  results  of  the  operation 
to  the  intended  lnisl)and. 

Disqualifications  from  Relationship. — Blood  relationship  generally 
disqualifies  those  within  the  third  degree,  inclusiv^e,  computed  according 
to  the  civil  law;  that  is,  those  nearer  to  each  other  than  first  cousins, 
whether  by  the  whole  blood  or  haK  blood,  by  legitimate  or  illegitimate 
connection. 

Some  States  also  prohibit  marriages  between  those  connected-  by 
affinity,  witliin  certain  degrees. 

Effect  of  Disqualifications. — By  the  common  law,  canonical  disabil- 
ities rendered  a  marriage  voidable  only ;  ci\-il  disabilities  might  render 
it  void.*  In  the  several  States  of  the  United  States  it  is  generally  held 
that  marriages  by  persons  under  any  disal)ility  are  simply  voidable,  and 
that  the  proper  mode  of  avoiding  them  is  T)y  an  application  for  a  divorce. 
In  some,  however,  the  common  law  rule  is  still  recognized. t 

Paternity  of  Children. — A  child  born  in  wedlock  is  legally  presmned 
to  be  legitimate.  This  jjresumption  is  not  overcome  by  proof  of  adultery 
on  the  part  of  the  wife  at  about  the  time  of  conception,  unless  it  is  also 
proved  that  the  husband  had  no  opj)ortunities  of  intercourse  with  her 
at  or  about  the  same  time.  Such  proof  must  be  so  strong  as  to  put  it 
beyond  all  reasonable  doubt  that  the  husband  could  not  have  been  the 
father.|  That  the  child  must  have  been  begotten  before  the  marriage 
does  not  affect  the  question  of  its  legitimacy. 


DIVORCE. 

Divorce  Procedure. — Divorces  are  of  two  kinds,  a  vinculo  matrimonii, 
or  from  the  bond  of  matrimony,  and  a  mensa  ef  tlwro,  or  from  bed  and 
board.  In  some  States  both  these  kinds  of  divorce  are  granted ;  in 
others,  only  the  former.  A  separation  is  also  not  infrequently  accom- 
plished by  mutual  consent,  upon  terms  and  settlements  arranged  through 
the  medium  of  trustees  for  the  wife. 

Divorces  in  the  United  States  generally  are  granted  only  under  con- 
ditions and  for  caiises  determined  by  the  statute  law  of  the  State  or 
Territory  where  one  or  both  of  the  parties  are  domiciled.  Some  States, 
however,  have  entertained  equitable  proceedings  to  declare  a  mari-iage 

^  2  Kent's  Commentaries,  9.5. 

t  Harrison  vs.  The  State,  22  Maryland  Rep.  468  ;  85  Am.  Dec.  658 ;  Bro-vnie's  Digest 
f>f  Divorce  Laws,  57.  ■' 

t  PMUps  vs.  AUvH,  2  Allen's  Rep.  454. 


520  ^   SYSTEM  OF  LEGAL  MEDICINE. 

mill  because  the  parties  were  not  of  sufficient  capacity  to  contract,  or 
for  fraud  in  procuring  it. 

Legislative  divorces,  by  a  special  statute  passed  to  meet  the  particular 
case,  are  also  granted  by  some  States  in  exceptional  instances,  for  other 
than  the  ordinary  statutory  causes.* 

The  United  States  have  no  laws  regulating  divorces,  except  as  to  per- 
sons belonging  to  the  District  of  Columbia.  In  some  States  provision 
is  made  by  law  for  the  intervention  of  a  public  prosecuting  officer  to 
make  defense  in  uncontested  divorce  suits,  when  he  thinks  such  a  course 
demanded  by  the  public  interests. 

Causes  of  Divorce  Antecedent  to  the  Marriage. — Want  of  sufficient 
age,  or  of  mental  or  physical  capacity,  or  relationship  within  the  prohib- 
ited degrees,  are  causes  of  divorce  antecedent  to  the  marriage.  So  also 
is  fraud  in  procuring  the  contract.  The  term  "  fraudulent  contract "  is 
sometimes  used  to  denote  only  marriages  where  one  of  the  parties  is  im- 
potent, thus  defrauding  the  other  of  one  of  the  expected  advantages  of 
the  union ;  or  where  both  are  so  related  as  to  make  the  contract  one  in 
fraud  of  the  law.t 

But  while  these  are  cases  of  constructive  fraud,  there  may  also  be- 
those  of  actual  fraud.  To  constitute  a  cause  of  divorce  for  actual  fraud,, 
the  fraud  must  be  plain  and  the  proof  clear.  Fraud  is  never  presumed. 
An  unchaste  woman  commits  no  legal  fraud  in  marrying  a  man  who  is 
ignorant  of  her  character.  If,  however,  she  mairies  when  actually  preg- 
nant by  another  man,  and  the  husband  was  ignorant  of  her  condition 
and  believed  her  chaste,  he  can  claim  a  divorce  on  the  ground  of  her 
f  raud4  It  is  otherwise  if  he  knew  that  she  was  unchaste,  though  he  did 
not  know  that  she  was  with  child.§  Should  she,  however,  while  in  this, 
condition,  under  false  representations  of  her  chastity  induce  him  to  en- 
gage to  marry  her,  and  then  entice  him  into  sexual  intercourse  before 
and  in  contemplation  of  the  marriage  and  for  the  very  purpose  of  pre- 
cluding him  from  afterward  claiming  a  divorce,  because  he  would  then 
have  married  her  knowing  by  his  own  act  that  she  was  unchaste,  such 
active  fraud  on  her  part,  coupled  with  her  pregnancy,  would  be  sufftcient 
to  give  him  a  divorce.  || 

Divorces  on  the  Ground  of  Impotence, — On  an  application  for  a 
divorce  on  the  ground  of  impotence,  the  court  may  require  the  defendant 
to  submit  to  a  surgical  examination,  unless  this  has  been  done  before 
the  institution  of  the  action,  and  the  result  can  be  shown  by  proper  testi- 
mony. A  certificate  by  the  examining  physician  is  not  receivable  in  lieu 
of  his  appearance  as  a  witness.^ 

Long  and  unexplained  delay  on  the  part  of  the  petitioner  in  seeking 
a  divorce  will  bar  the  remedy.  Ignorance  of  the  existence  of  the  defect 
will  not  excuse  the  delay,  if  there  was  the  means  of  knowledge,  and  a. 
want  of  reasonable  diligence  in  seeking  to  obtain  it.** 

*  Maynard  vs.  Hill,  125  U.  S.  Rep.  190 ;  Starr  vs.  Pease,  8  Coun.  Rep.  541. 

t  Benton  vs.  Benton,  1  Day's  Rep.  114. 

X  Scott  vs.  Shitfelt,  5  Paige's  Rep.  43. 

^  Crehore  vs.  Crehore,  97  Mass.  Rep.  330. 

II  Seilheimer  vs.  Seilheimer,  40  N.  J.  Eq.  Rep.  412 ;  2  Atl.  Rep.  376. 

^  DevenhaghYS.  Bevenhagh,  5  Paige's  Chan.  Rep.  554 ;  LcBarrou  vs.  LeBarron,  35  Vt. 
365. 

**  Newell  vs.  Newell,  9  Paige's  Chan.  Rep.  25 ;  B n  vs.  B n,  28  Eng.  Law  and 

Eq.  Rep.  95. 


MARRIAGE  AND  DIVORCE.  521 

It  is  not  necessary  to  prove  impotence  generally,  and  as  to  all  women. 
It  is  enough  to  establish  its  existence  so  far  as  the  intercourse  with  the 
petitioner  is  concerned.  A  failure  to  consummate  the  marriage  after 
three  years  of  c<)lial)itation  is  presumptive  evidence  of  impotence.* 

Causes  of  Divorce  Arising  after  the  Marriage — Insanity — Cruelty. 
— We  have  already  seen  that  loss  of  2)liysical  power,  occuiring  after  the 
marriage,  is  no  ground  for  a  divorce.  The  same  is  true  in  most  States 
as  to  loss  of  reason,  even  if  a  i)ennanent  affection,  though  this  is  some- 
times, in  such  jurisdictions,  made  the  subject  of  a  divorce  by  a  special 
act  of  the  legislature.t 

It  is  not  a  cause  of  divorce  on  the  ground  of  ''  intolerable  ciiielty " 
that  a  husband  insists  on  sexual  intercourse  against  the  wishes  and  re- 
monstrances of  the  wife,  although,  in  consequence  of  her  physical  con- 
dition, this  is  indelicate,  iiyproper,  unreasonable,  and  injurious  to  her 
health,  unless  he  knew  that  her  condition  and  health  were  such  as  to 
make  the  act  unreasonable.t  If  he  had  such  knowledge,  his  acts  would 
violate  his  marital  obligations.  There  is  a  duty  of  forbearance  on  the 
part  of  the  husband  at  the  reasonable  request  of  the  wife,  as  well  as  a 
duty  of  sul  )mission  on  her  part  at  his  reasoiuil^le  request.§ 

The  willfid.  communication  of  venereal  disease  by  one  party  to  the 
other  may  amount  to  such  an  act  of  cruelty  as  to  justify  a  divorce ;  and 
knowledge  of  the  existence  of  the  disease  on  the  part  of  the  party  affected 
may  be  inferred  from  the  mere  fact  of  its  existence. 

It  is  not  "  cruel  and  abusive  treatiuent "  within  the  meaning  of  divorce 
statutes  for  a  wife  to  refuse  for  years,  without  cause,  to  have  any  sexual 
intercourse  with  her  husband.] |  The  old  law  of  England  gave  a  remedy 
in  such  a  case,  by  a  suit  for  the  "restitution  of  conjugal  rights,"'  result- 
ing in  the  punishment  of  the  offending  party  by  imprisonment  for  con- 
tempt of  court,  should  the  refusal  be  continued  after  a  judgment  in  favor 
of  the  petitioner ;  but  this  proceeding  was  founded  on  principles  of  eccle- 
siastical law,  applicable  to  courts  having  in  view  the  preservation  of  the 
morals  of  the  parties  before  them,  and  acting  pro  salute  animcB. 

Divorces  for  Ili=treatment  Injuring  Health  or  Endangering  Rea- 
son.— In  some  States  divorces  are  gi-anted  for  acts  which,  though  not 
amounting  to  extreme  cruelty  in  the  legal  sense,  yet  are  such  as  seriously 
to  injure  the  health  or  endanger  the  reason  of  the  other  party. 

In  applying  such  laAvs  the  temperament  of  the  sufferer  is  to  be  re- 
garded. The  health  or  reason  of  a  feeble  or  neurotic  person  might  be 
■endangered  by  such  a  slight  degree  of  ill-treatment  as  would  have  httle 
or  no  eifect  on  a  healthier  subject.  Divorce  is  not  intended  as  a  pun- 
ishment of  the  offender,  but  as  a  relief  to  the  j)arty  against  Avhom  the 
offense  is  committed.^] 

If  a  man  compels  his  \\'ife  to  submit  to  sexual  intercourse  so  fre- 
quently as  to  impair  her  health,  it  mil  be  a  sufficient  ground  of  divorce, 
under  a  law  of  this  character.** 

*  A)i()in/mniis,  22  Eng.  Law  and  Eq.  Eep.  637. 

t  See  Cooler's  edition  of  Blackstoue's  Commentaries,  vol.  i.,  p.  441,  note  23. 

I  Shair  vs.  Sliair,  17  Conn.  Kep.  189. 

v^  M((iiJicw  vs.  M/n/]ic)r,  61  Conn.  Rep.  235. 

II  Cni'rlrs  vs.  CoirJrs.  112  Mass.  Kep.  298. 

^  R(>hi)iso)i  vs.  liobinsoii,  (New  Hampshire)  23  Atl.  Eep.  362. 

**  Mrh'i)i  vs.  Melvin,  58  N.  H.  Rep.  569 ;  Grant  vs.  Grant,  (Minnesota)  54  Xortliwest. 
Eep.  1059. 


522  ^  SYSTEM  OF  LEGAL   MEDICIXE. 

Divorces  on  Account  of  Loathsome  Disease. — lu  some  States  it  is 
a  gi'ound  of  divorce  if  either  party  "0"as  affected  at  the  time  of  maiTiage 
■with  a  loathsome  and  ineui'able  disease  (such  as  lei^rosv  or  s^-philis), 
aud  failed  to  inform  the  other  party  of  this  fact*  If  the  knowledge  of 
the  disease,  when  gained,  brought  such  mental  anguish  as  to  endanger 
health  or  create  a  reasonable  apjDrehension  of  such  danger,  the  act  of 
concealment  may  be  considered  as  such  -  cruel  and  alnisive  treatment " 
as  to  justify  a  divorce,  under  a  statute  embracing  that  as  a  sufficient 
cause.! 

Divorces  for  Adultery. — To  constitute  adulteiy  there  must  be  a 
"Wrongful  intent.  If  the  woman  is  violated  by  force,  or  submits  to  sexual 
intercourse  while  insane,  or  with  one  whom  she  supposes  to  be  her  hus- 
band, there  is  no  gi'ound  for  a  divorcer  It  is,  however,  held  in  some 
States  that  insanity  is  no  answer  to  a  libel  for  adulter}^,  and  that  the 
consequences  of  the  act  are  to  be  regarded,  rather  than  the  guilty  pur- 
pose of  the  wife.§     In  no  State  would  m-mphomania  be  any  excuse. 

Proof  that  the  husl:)and  has  the  venereal  disease,  and  that  it  fii'st  be- 
came apparent  some  time  after  marriage,  does  not  show  that  it  was  not 
conti'aeted  before  the  marriage,  and  is  therefore  not  sufficient  proof  of 
the  commission  of  adulteiy. 

Divorces  for  Habitual  Drunkenness. — Proof  of  ocasional  intoxica- 
tion does  not  suffice  to  show  habitual  drunkenness.  Indulgence  in  the 
use  of  chloroform,  or  of  moii^hine  by  hypodermic  injections  or  other- 
wise, though  habitual  and  carried  to  excess,  is  not  drunkenness.  Intoxi- 
cation by  the  immoderate  and  habitual  use  of  '"intoxicating  liquors''  as 
a  beverage  must  be  estaldished.;! 

Divorces  for  Desertion. — The  refusal  of  a  wife  to  permit  sexual  in- 
tercourse, though  uni"easonably  continued  for  a  consiclerable  period  of 
years,  does  not  constitute  deseition  of  her  husband,  so  long  as  she  re- 
mains a  member  of  his  household  and  under  his  roof.'] 

Divorces  where  One  Party  is  Insane. — A  petition  for  a  divorce 
may  be  brought  by  an  insane  husband  or  wife,  suing  by  a  guardian  or 
a  committee  appointed  by  a  proper  court  :**  and  against  an  insane  hus- 
band or  wife,  for  an  offense  committed  while  sane,  or  for  insanity  exist- 
ing at  the  date  of  the  man-iage.  Such  a  petition  is  not  supported  by 
proof  of  the  existence  of  temporary  paroxysms  of  insanity  before  mar- 
riage, of  which  the  petitioner  had  no  knowledge,  even  though  after  mar- 
riage permanent  insanity  ensued.ff 

Divorces  by  Consent. — Any  ordinaiy  contract,  as  it  is  made  by 
the  mutual  consent  of  the  parties  to  it,  can  be  also  rescinded  by  their 
mutual  consent.  Marriage  being,  as  ali-eady  stated,  something  more 
than  a  contract,  is  not  thus  dissoluble.  On  the  contrary,  courts  look 
with  suspicion  on  any  divorce  proceeding,  though  good  cause  be  shown, 
where  there  is  gi-ound  for  belicA-ing  that  both  parties  are  willing  that 

*  See  Maynard  vs.  HiU,  125  TJ.  S.  Rep.  205. 

t  Leach  vs.  Leach,  (Maine)  8  Atl.  Rep.  349. 

t  Schouler  on  HvKhniul  and  Wife.  ^  504. 

^  Machin  vs.  Machiii,  6  BaiT's  Peun.  Rep.  332. 

II  Yotnu/s  vs.  Yotiwjs,  130  111.  Rep.  230 ;  22  Northeast.  Rep.  806. 

51  Soutliurick  vs.  Sonthirick,  97  Mass.  Rep.  327. 

**  Cotran  vs.  Conan,  139  Mass.  Rep.  377. 

tt  Hamaker  vs.  Hamakcr,  18  111.  Rep.  137;  65  Am.  Dec.  705. 


MAnniAGE  AND   DIVORCE.  523 

tlie  petition  should  be  granted ;  and  if  such  willingness  amounts  to  col- 
lusion, a  divorce  will  usually  l)e  refused.* 

Recrimination  as  a  Defense. — A  petition  grounded  on  adultery  may- 
be defeated  l)y  proof  of  adultery  on  the  part  of  the  petitioner.  Denial 
l)y  the  wife  of  sexual  intercourse,  tliough  long  continued  and  without 
justification,  is  not  a  defense  to  a  j)etition  by  her  for  a  divorce  on  the 
ground  of  adult(:'ry.  It  has  been  held  no  defense  to  her  petition  grounded 
on  desertion,  and,  on  the  other  hand,  desertion  by  the  wife  has  been  held 
a  sufficient  answer  to  her  petition  grounded  on  adultery.t 

Extreme  cruelty,  if  a  statutory  ground  of  divorce,  may  l)e  shown,  in 
most  States,  to  defeat  a  petition  In'ought  for  the  cause  of  adultery .| 

Condonation  as  a  Defense. — If  either  party  to  the  marriage  has  a 
cause  of  divorce  arising  from  the  misconduct  of  the  other,  it  can  be 
w^aived  or  condoned  by  forgiveness.  Occupying  the  same  sleeping-apai-t- 
ment  with  the  offender,  after  knowledge  of  the  offense,  is  a  sufficient 
condonation  to  bar  the  divorce.§  Occupying  the  same  house  affords  a 
presumption  of  full  marital  cohabitation,  but  one  that  can  be  explained 
by  evidence  to  the  contrary.  Condonation  is  less  readily  presumed  on 
the  part  of  the  ^\\te,  since  she  is  the  weaker  party,  and  in  a  position  of 
greater  dependence. 

Testimony  in  Divorce  Suits. — The  rules  of  evidence  in  ordinary 
cases  do  not  permit  husband  and  wife  to  testify  against  each  other. 
This  doctrine  is  founded  on  public  policy,  to  promote  the  peace  of  the 
household  and  support  the  institution  of  marriage.  ||  But  in  divorce 
j)roceedings,  or  in  case  of  resort  to  the  courts  by  one  for  protection 
against  the  violence  of  the  other,  each  party,  from  the  necessity  of  the 
case,  is  admissible  as  a  witness.^] 

The  results  of  any  physical  examination  made  by  experts  must,  in 
this  country,  be  given  by  the  examiners,  testifying  as  witnesses  under 
oath.  We  have  not  adopted  the  English  practice  of  accepting  a  certifi- 
cate of  the  result  from  official  inspectors. 

*  Danforth  vs.  Danforih,  105  111.  Kep.  603. 

+  Schouler  ou  Hushand  and  Wife,  ^  536. 

X  Church  vs.  Church,  16  Ehode  Island  Eep.  667;  19  Atl.  Eep.  244. 

§  Rogers  vs.  Rogers,  122  Mass.  Rep.  423. 

II  Lvcas  vs.  Brooks,  18  Wallace's  U.  S.  Rep.  436. 

i[  2  Bishoi^  ou  Marriage  and  Divorce,  $  287. 


SEXUAL   CRIMES. 

BY 

CHARLES  GILBERT   CHADDOCK,  M.D. 

RAPE. 

Legal  Considerations. — Rape  constitutes  an  offense  in  common  law, 
but  its  legal  definition  varies  in  the  statutes  and  codes  of  various  States, 
particularly  with  respect  to  the  bearing-  of  the  age  of  consent  ujjon  the 
crime.  Rape  is  carnal  knowledge  of  a  woman  by  a  man,  unlawfully  and 
by  means  of  force,  against  the  will  and  without  the  consent  of  the 
woman.  On  the  jjoints  of  ''will"  and  "consent"  there  have  been  decis- 
ions in  Arkansas,  Florida,  Micliigan,  Nevada,  and  Wisconsin.  Thus  rape 
may  be  committed  when,  in  sensii  stricfiori,  the  woman  shows  no  will  at 
all ;  as  when  she  is  narcotized,  or  in  a  state  of  non  compos  mentis.  Carnal 
knowledge  may  also  be  rape  where  it  takes  place  with  consent  that  has 
been  obtained  through  fear  or  fraud.  Absence  of  consent  is  interpreted 
as  equivalent  to  being  against  the  will  of  the  woman,  in  later  EngHsh 
law.  Rape  is  possible  only  in  case  of  physical  capacity  in  the  direct  male 
perpetrator;  but  impotence  is  no  defense  for  intent  to  commit  rape  where 
it  cannot  be  shown  tliat  the  pei-petrator  was  aware  of  his  sexual  inca- 
pacity. The  age  of  the  male,  in  its  effect  upon  capacity  to  commit  rape, 
may  be  of  importance  in  determining  the  conditions  constituting  the 
crime.  A  male  under  the  age  of  fourteen  cannot  commit  rape,  accord- 
ing to  English  law ;  but  in  the  United  States  a  few  courts  have  held  that 
there  is  no  conclusiv^e  presumption  of  incapacity  determined  by  age.* 
The  crime  of  rape  may  be  perpetrated  upon  the  person  of  any  female, 
no  matter  what  her  age,  character,  or  capacity. 

Since  the  question  of  consent  is  of  prinuiry  importance  in  its  l)earing 
upon  the  crime,  the  age  of  the  female,  as  affecting  her  legal  capacity  to 
give  consent  to  sexual  intercourse,  is  of  the  greatest  importance.  In 
common  law,  a  child  that  has  not  attained  the  age  of  ten  years  is  pre- 
sumed to  be  incapable  of  giving  consent.  Therefore,  in  geni'ral,  carnal 
knowledge  of  such  a  child  is  felony.  But  statutes  in  England  and  in  many 
of  the  United  States  make  carnal  knowledge  of  a  child  between  the  ages 
of  ten  and  twelve  a  misdenu^anor.  If,  under  such  circumstances,  the 
cliiUl  consents,  the  offense  is  a  misdemennor,  not  an  assault.  The  age  of 
<'onsent  in  a  majority  of  the  States  is  foui-teeu  years.  A  New  York  statute 
nuikes  it  rape  for  a  man  to  have  sexual  intercourse  with  a  fen^de  to 
whom  he  is  not  married  who  is  under  the  age  of  sixteen.     It  is  felony 

*  New  York,  Ohio,  Tennessee,  Kentucky. 


526  ^  SYSTEM  OF  LEGAL  MEDICINE. 

for  a  man  to  liave  carnal  knowledge  of  a  child  who  is  under  the  age  of 
ten,  in  Arkansas,  Michigan,  Mississippi,  North  Carolina,  Wisconsin,  and 
Texas.  Intercourse  with  a  child  under  the  age  of  twelve  years  is  rape 
under  tlM  Code  of  Louisiana.  The  age  of  consent  is  fixed  at  fifteen 
years  in  Nebraska ;  at  thirteen  in  Iowa ;  at  sixteen  in  Pennsylvania ;  at 
eighteen  in  Wyoming  and  Kansas.  In  Ohio,  decisions  have  been  less 
stringent;  the  knowledge  of  the  child  has  been  taken  into  consider- 
ation. 

Actual  carnal  knowledge  must  be  shown  by  direct  or  indirect  evi- 
dence, in  order  to  establish  the  crime  of  rape.  Penetration,  in  the  least 
extent,  of  the  female  genitals  by  the  male  organ,  constitutes  carnal  knowl- 
edge. Force,  actual  or  its  equivalent,  is  necessary  to  the  commission  of 
rape ;  and  the  force  must  have  been  sufficient  to  accomplish  the  purpose. 
Submission  obtained  by  means  of  fear  or  terror  induced  by  threats  or 
otherwise,  is  construed  as  the  result  of  moral  force  equivalent  to  a  com- 
pelling degree  of  physical  force.  In  law,  intercourse  accomplished  by 
means  of  fraud,  where  there  was  no  intent  to  use  violence,  is  not  rape. 
Within  the  age  of  consent,  where  consent  is  given,  no  matter  how  re- 
luctantly, there  can  be  no  rape.  The  female  must  have  offered  all  pos- 
sible resistance,  or  resistance  must  have  been  made  impossible  by  terror 
or  other  means.  Commonly,  connection  with  a  woman  while  she  is  un- 
conscious, as  during  sleep  or  insensibility  occasioned  by  alcohol  or  other 
narcotics,  is  rape ;  and  the  same  is  true  in  cases  of  idiocy  and  imbecility,, 
though  in  New  York  this  is  merely  a  crime  against  the  person. 

The  prosecutrix  in  a  trial  for  rape  is  a  competent  witness ;  but  in  case 
the  defendant  denies  guilt,  her  testimony  must  be  corroborated  as  to 
material  facts,  though  the  fact  of  the  rape  need  not  be  proved  by  other 
witnesses. 

The  foregoing  paragraph  shows  that  there  will  be  many  cases  of  the 
crime  of  rape  in  which  no  technical  medical  testimony  will  be  required ; 
but  -frequently  medical  evidence  will  be  called  for — not  in  any  sense  tO' 
define  legally  an  act  of  sexual  congress,  but  to  assist  in  the  determina- 
tion of  the  question  whether  sexual  contact  has  taken  place  or  not.  The 
physician  may  be  required  to  give  evidence  concerning  facts  which  indi- 
cate whether  coitus  has  taken  place  or  not ;  or  he  may  be  asked  to  give 
testimony  concerning  any  evidences  of  physical  force  used  in  the  accom- 
plishment of  sexual  intercourse. 

Conditions  that  Indicate  that  Coitus  has  Taken  Place. — Physio- 
logically, coitus  consists  of  immissio  penis  and  eniissio  seminis  ;  but  the 
latter  is  not  essential  to  the  crime  of  rape.  Moreover,  immissio  penis  need 
not  have  been  complete,  the  slightest  penetration  of  the  female  genitals 
by  the  male  organ  being  sufficient  in  the  legal  sense.  For  the  purposes 
of  diagnosis,  attention  must,  of  course,  be  directed  to  the  female ;  for 
examination  of  the  male  can  reveal  nothing,  save  in  those  cases  where 
the  demonstration  in  him  of  venereal  disease  or  of  marks  on  his  person 
indicative  of  resistance  offered  by  the  female  is  of  importance. 

Examination  of  the  female  will  have  for  its  object  the  determination 
of  the  existence  of  anatomical  conditions  or  changes  affecting  her  geni- 
tals that  indicate  whether  coitus  has  taken  place  or  not;  whether  there 
are  evidences  of  the  ejaculation  of  semen  in  or  about  her  genitals  and 
clothing;  wliether  her  person  presents  signs  of  violence;  and  whether 
there  is  any  existing  venereal  disease  or  evidence  of  its  previous  existence. 


SEXUAL  CRIMES.  527 

The  Anatomical  Changes  of  the  Female  Genitals  Induced  by  the 
First  Act  of  Coitus. — In  females  that  have  had  coitus  many  times,  and 
in  those  that  have  home  ehildren,  the  changes  that  have  taken  place  in 
the  form  and  condilion  of  the  genitals  are  necessarily  of  such  a  nature 
that  a  single  act  of  normal  coition  would  leave  no  immediate  anatomi(!al 
evidence  of  its  occurrence.  The  repetition  of  tlie  act  of  sexiud  inti^-- 
course,  and,  much  more,  the  occurrence  of  lal)or,  enlarge  the  genital 
passage  and  render  its  tissues  yielding,  so  that  the  single  act  of  coitus 
takes^place  without  leaving  a  change  in  the  parts.  Still,  even  under 
these  circumstances,  the  act  may  be  done  with  such  brutality  as  to  leave 
marks  in  the  form  of  abrasions  and  lacerations.  In  the  vast  majority  of 
instances  of  rape,  however,  the  crime  is  committed  on  virgins ;  and  often 
in  such  cases  the  questions  the  physician  may  be  called  upon  to  answer 
are  :  (1)  Is  the  alleged  victim  a  virgin?  (2)  Do  the  genitals  present  evi- 
dence of  recent  or  remote  defloration'? 

In  a  virgin,  as  a  rule,  the  labia  majora  are  firm,  large,  and  well- 
rounded,  theii-  edges  lying  in  intimate  contact  in  the  median  line,  and 
completely  covering  the  labia  minora ;  the  labia  -aninora  present  a  bright 
red  color ;  the  vestibule  is  narrow ;  the  hymen  is  intact ;  the  vagina  is 
narrow,  and  presents  prominent  folds  of  its  Avails. 

While  the  state  of  the  Jahia  majora  mentioned  usually  accompanies 
virginity,  it  is  not  a  sign  of  much  determinate  value.  The  size  and  posi- 
tion of  the  labia  with  relation  to  each  other  depend  in  great  nieasure  upon 
the  character  and  amount  of  subcutaneous  adipose  tissue  in  the  parts. 
In  healthy  vii-gius  there  is  usually  an  abundance  of  subcutaneous  fat, 
and  in  consequence,  the  labia  are  full,  well-rounded,  and  in  close  contact. 
Even  in  such  instances,  however,  the  labia  readUy  separate  with  separa- 
tion of  the  thighs,  and  this  must  be  remembered  in  any  conclusions  drawn 
from  examinadon  of  the  labia.  Anything  that  leads  to  deficiency  of  sub- 
cutaneous adipose  tissue  may  alter  the  relations  of  the  labia  and  cause 
them  to  separate  more  or  less  completely.  In  thin  subjects,  whether 
chUdi-en  or  virgins,  the  examiner  must  expect  to  find  more  or  less  defi- 
ciency of  median  contact  of  the  labia ;  but,  on  the  other  hand,  if  a  female 
is  well-nourished  and  youthful,  the  labia  may  stiU  be  in  close  contact, 
even  though  coitus  has  been  performed  many  times.  Again,  as  age  ad- 
vances the  subcutaneous  areolar  tissue  loses  that  firmness  characteristic 
of  youth,  and  in  consequence,  though  w^ell-nourished  and  a  virgin,  a  fe- 
male beyond  the  years  of  youth  may  show  marked  separation  of  the  labia. 
From  these  facts"^  it  will  be  seen  that  the  conditions  and  relations  of  the 
labia  depend  more  upon  the  general  condition  of  health  and  age  than 
upon  whether  coitus  has  taken  place  or  not. 

The  condition  of  the  lahia  minora  depends  largely  upon  the  condition 
of  the  labia  majora.  As  long  as  the  nymplia?  are  covered  by  the  latter, 
the  membrane  covering  them  retains  its  original  characteristics ;  it  is 
moist,  and  presents  a  rosy  tint.  After  alteration  of  the  position  of  the 
Libia  majora  induces  constant  exposure  of  the  nympha%  the  mucous  meni- 
brane  covering  them  undergoes  changes  wliieh  cause  it  to  resemble  epi- 
dermis. It  is"  less  moist,  and  the  rosy  hue  changes  to  a  distinct  brown. 
This  dependence  of  the  condition  of  tlie  labia  minora  upon  the  condition 
of  the  labia  majora  allows  no  absolute  value  to  attach  to  the  condition 
of  the  nymphjTp  in  determining  the  question  of  virginity. 

The  condition  of  the  lu/iuen  is  of  much  greater  value  as  evidence  of 


528  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

"^   ATi'ginity  or  defloration.     But  even  the  state  of  this  membrane  will  not 

always  save  from  an  eiToneons  conclusion.     The  hymen  is  not  always 

ruptui-ed  in  the  first  coitus ;  it  has  been  found  intact  even  after  labor. 

Moreover,  the  hymen  may  be  altered  by  other  means  than  the  penetra- 

•  tion  of  the  male  organ. 

The  hj-men  frequently  presents  anomalies  and  defects,  as  well  as 
variations  of  form  of  slighter  degree ;  and  an  understanding  of  these 
possibihties  is  of  great  importance  for  a  correct  appreciation  of  the 
changes  in  the  hjTuen  induced  by  coitus. 

The  hjTuen  is  commonly  regarded  as  merely  a  fold  of  mucous  mem- 
brane closing,  more  or  less  perfectly,  the  entrance  of  the  vagina ;  but 
Pozzi  *  has  shown  it  to  be  a  structui-e  of  much  more  definite  morphology. 
The  hymen  makes  its  appearance  somewhat  late  in  fetal  life,  for  it  can- 
not be  distingiiished  until  after  the  fourth  month,  when  the  differentia- 
tion of  the  genital  organs  has  become  quite  complete.  At  fu-st  it  is  seen 
as  two  folds  which  apx)ear,  one  on  each  side,  at  the  opening  of  the  uro- 
genital sinus.  Advancing  in  development,  these  two  folds  meet  and  fuse 
in  the  median  Hue,  lea^'ing  at  the  vaginal  orifice  the  hsineneal  opening. 
The  primitive  folds  of  the  hymen  extend  forward  fi'om  the  ostium  vaginae 
to  the  base  of  the  clitoris,  forming  a  cii'cular  fold  about  the  orifice  of  the 
nrethi-a,  and  uniting  in  the  median  line  of  the  vestibule  to  form  the 
frenum  masculinum.  Thus,  morphologically,  the  hymen  is  the  repre- 
sentative of  the  male  corpus  spongiosum,  and  it  is  to  be  regarded  as  an 
organ  modified  by  arrest  of  develoj)ment. 

In  the  infant  the  hymeneal  folds  are  well  developed  and  prominent,  but 
the  vestibule  hes  deeply  between  the  labia.  It  is  pointed  out  by  Pozzi  t  that 
when  the  hymen  has  the  labiated  form  (two  lateral  folds),  in  the  iufant 
it  might  be  mistaken  for  the  nymphae,  owing  to  the  considerable  size  of 
the  folds  at  an  early  period  of  life,  and  lead  the  observer  to  conclude 
that  the  hymen  is  absent  or  destroyed.  The  possible  medico-legal  im- 
portance of  such  an  error  is  apparent.  In  children  at  bii'th,  owing  to 
the  depth  of  the  vestibule,  the  hymen  is  more  deeply  placed  than  later 
in  life.  However,  this  infantile  peculiarity  may  jjersist  in  youth  and  be 
found  even  in  adult  life.  Tm-nipseedt  states  that  in  the  negro  race  this 
peeuharity  is  very  marked.  Such  a  deep  situation  of  the  Inmien,  espe- 
cially in  adults,  might  lead  to  the  erroneous  conclusion  that  it  is  absent. 

Congenital  absence  of  the  hjonen  is  certainly  very  rare.  Modern 
observers  are  in  accord  in  stating  that  they  have  never  met  with  an  in- 
stance of  it.  The  cases  of  it  reported  by  older  "winters  are  probably  ex- 
amples of  en'oneous  conclusions  due  to  a  want  of  knowledge  of  the 
I)ossible  variations  in  form  and  situation  to  which  the  hymen  is  now 
known  to  be  subject. 

In  stracture  the  hymen  is  usually  thin  and  membraniform.  It  is 
made  up  of  the  folds  previously  mentioned,  which  lie  in  apposition. 
These  lateral  folds  may  remain  perfectly  distinct ;  but  usually  they  are 
fused  together  more  or  less  perfectly,  commonly  leaving  a  single  opening 
into  the  entrance  of  the  vagina.  In  some  cases,  however,  there  are 
marked  deviations  from  the  ordinary  structui-al  characteristics.     The 

*  S.  Pozzi:  "De  la  Bride  Masc,"  etc.,  BulL  et  Mem.  Soc.  Biolog.,  Januaiy  26  and 
Febniary  16,  1884. 

*  Gi/)iecolof/!/,  vol.  ii.,  p.  44.3. 

X  Am.  Jour,  of  Ohstet.,  1877,  vol.  x. 


SEXUAL   CRIMES. 


529 


hymen  may  be  found  tliiek  and  fleshy;  or  it  may  be  so  dense  and  inelas- 
tic as  to  present  an  obstacle  to  normal  coitus  which  the  male  organ  can- 
not overcome.  On  the  other  hand,  the  liymen  may  be  so  elastic  and 
yielding"  as  to  survive  uninjured  the  strain  of  coitus,  or  even  that  of 
labor.  However,  instances  of  the  latter  kind  must  l)e  exceedingly  rare. 
Tlie  condition  of  an  uninjured  hymen  might  be  of  some  value  in  de- 
termining the  question  of  coitus.  A  dense,  unyielding  liymen  would 
positively  exclude  complete  penetration,  providing  its  opening  were  suffi- 
ciently small  to  prevent  iniDiissio  penis.  On  the  contrary,  an  uninjured 
hymen  of  exceptional  elasticity  would  not  prove  that  the  act  of  coition 
had  not  been  ])erformed.  It  should  also  be  renuMul)ered  that  it  is  pos- 
sible to  dilate  the  hj^neneal  orifice  gradually  without  gross  injiuy  to  its 
tissues.  By  this  means  ruptiu-e  of  the  hymen  is  avoided  in  the  gyneco- 
logical treatment  of  virgins.  Exceptionally,  the  hymen  is  exceedingly 
vascular,  and  in  such  cases  its  rupture  may  be  attended  ^xiih.  alarming 
and  even  fatal  hemorrhage.  Cases  of  multiple  hpnen  have  been  re- 
ported ;  but  all  such  instances  are  to  be  explained  as  the  residts  of  path- 
ological adhesion  of  the  vaginal  walls.  Such  adhesions  usually  occur 
early  in  life,  if  at  all,  and  they  may  persist  up  to  adult  age. 

Since  the  hymen  is  developed  from  two  lateral  lamintp,  as  might  be 
expected,  in  childhood  it  is  usually  found  in  the  labiated  form.  Gradu- 
ally these  original  laminaj  be- 
come fused  in  various  ways,  lead- 
ing to  a  great  variety  of  forms  of 
the  fully-developed  hymen.  In 
the  adult  the  hymen  is  most  com- 
monly anmiJar  in  form  (Fig.  69) ; 
but  this  tjTpe  has  received  vari- 
ous names  in  accordance  with  the 
variations  of  form  produced  by 
variations  of  the  position  of  the 
hymeneal  oriiice.  Infrequentl}^ 
the  opening  is  found  occupying 
a  central  position  in  the  mem- 
brane. More  commonly  the  ori- 
fice lies  in  the  anterior  haK  of  the 
mend)rane.  The  shape  of  the 
hymen  varies  also  in  accordance 
with  the  size  and  form  of  the 
opening.  The  hymeneal  aper- 
ture nuiy  be  circular,  but  more 
commonly  it  is  oval,  with  its 
long  diameter  l.ying  antero-pos- 

terioi-ly.  The  diameter  of  the  opening  varies  widely.  It  may  be  so  nar- 
row, both  in  childn^i  and  adults,  as  merely  to  allow  the  passage  of  an 
ordinary  soimd  (10  mm.);  or  it  iwaj  be  so  large  that  the  hymen  forms 
scarcely  any  obstruction  at  the  entrance  of  the  Aagina.  Inqteyforate 
Jiijnien,  while  occasionally  observed,  is  certainly  a  rare  condition ;  more 
commoidy  the  atresia  of  the  vagiiui,  presumed  to  be  due  to  imperforate 
hymen,  is  due  to  an  imperforate  ct)ndition  of  the  vaginal  canal  itself. 
Under  such  circumstances,  the  hymen  is  fouiul  in  close  contact  with  the 
imperforate  membrane  derived  from  the  fusion  of  the  vaginal  walls,  the 


Fig.  (lit.— Annular  hymen.    (After  Hofmann.) 


530 


A   SYSTJSM   OF  LEGAL  MEDICINE. 


hjonen  presenting  its  normal  perforation.  When  the  hymeneal  opening 
is  comparatively  large,  and  anteriorly  situated,  the  hjanen  has  the  cres- 
centic  form  (also  called  falciform).  (Figs.  70  and  71.)  A  crescentic  hymen 
with  the  orifice  lying  posteriorly,  and  the  membrane  anteriorly,  is  nn- 


Fig.  70.— Crescentic  hymen.    (Roze.) 


Fig.  71. — Crescentic  hymen,  horseshoe.     (Roze.) 


known.  When  the  opening  is  long  and  narrow,  running  antero-poste- 
riorly,  the  membrane  is  practically  made  up  of  two  symmetrical  lateral 
halves,  and  the  hymen  is  then  said  to  be  lahiated — a  persistence  of  the 
common  infantile  form. 


Fig.  73. 


-Hymen  fimhriatus,  intact. 
Hofmann.) 


(After 


Fig.  73.- 


-Ruptured  hymen  fimhriatus. 
(After  Hofmann. ) 


The  free  edge  of  the  hymen  bounding  its  orifice  is  subject  to  much 
variation  in  form,  and  this  occasions  a  variety  of  forms  of  hymens.  In 
many  cases,  when  the  membrane  is  made  tense,  its  free  margin  may  be 
traced  as  an  unbroken  line,  forming  a  ring  or  semicircle,  as  the  case 
may  be.     Aside  from  variation  in  general  outline,  however,  the  free  edge 


SEXUAL    CHIMES. 


531 


may  present  various  irregularities.  It  is  frequently  found  notched. 
These  indentations  of  the  free  margin  may  l)e  situated  anteriorly  or 
posterioi'ly,  l)ut  their  most  eommon  seat  is  in  the  anterior  part  of  the 
membrane.  Usually  the  meml)rane  is  notched  symmetrically  on  each 
side.  The  notches  vary  in  depth,  from  a  slight  irregularity  of  the  edge 
of  the  memhrane  to  division  of  the  membrane  down  to  the  vaginal  wall. 
Thus  two  deep  notches  symmetrically  placed,  one  on  each  side,  may  divide 
the  hynuMi  into  four  parts.  There  may  be  an  anterior  and  a  posterior 
notch  on  each  side.  These  natural  irregularities  of  the  free  margin  of 
tlie  liyiiien,  when  present,  are  of  some  medico-legal  iinportau(;e.  Careless 
observation  might  mistake  them  for  artificial  tears  that  had  healed.  Close 
examination  of  such  natiu-al  not(;hes  will  show  the  absence  of  cicatri- 
cial tissue  and  the  integrity  of  the  mucous  meml)rane  covering  them.  In 
rare  instances  the  free  edge  of  the  hymen  presents  a  large  luimber  of  shal- 
low notches ;  and  still  more  rarely  it  may  be  fringed  {hynioi  finihviatns, 
Figs.  72  and  73).  The  hymeneal  orifice  nuiy  be  found  divided  b}-  a  narrow 
l)aud  of  membrane  [lupnen  S(Lptus).  The  meml)ranous  septum  di^•iding 
the  orifice  usually  extends  autero- posteriorly,  either  in  the  median  line  or 
somewhat  ol:)liquely.  The  two  hymeneal  openings,  under  such  circum- 
stances, may  be  approximately  equal,  or  very  unequal,  in  size ;  commonly 
they  are  manifestly  unequal.  (Fig.  74.)  The  hjaneu  sa?ptus  has  been  looked 
upon  as  a  proof  of  the  origin  of  the  hymen  in  the  Mlillerian  structures ;  but, 
as  previously  shown,  other  considerations  must  cause  the  abandonment  of 


mg^m^^^%.t\  fm  ^^i^--' 


i:^ 


1>V! 


^. 


X 


Fig.  74.— Hymen  sa-pi  iis.  \\\\\\  unequal  open- 
ings.    (Alter  llofiuaun.) 


Fig.  7.5.- 


-Hymen  with  posterior  rudimentary, 
septum.     (After  Hofmann.) 


this  view.  In  some  instances  but  one  lateral  hymeneal  orifice  is  fotmd,  the 
other  having  become  closed.  In  other  instances  the  septum  is  found  at- 
tached to  the  edge  of  the  hymen  only  at  one  point,  so  that  it  forms  a  long, 
slender  process.  (Fig.  75.)  In  very  rare  cases  the  hynuui  presents  a  large 
number  of  small  perforations,  constituting  the  variety  called  (■riJ»-ifon)i. 
In  the  normal,  itnstrained  position  of  the  genitals,  the  hymen  does 
not  present  at  the  opening  of  the  vagina  as  a  tense  membrane  ;  rather  it 


532 


A   SYSTEM   OF  LEGAL  MEDICINE. 


is  seen  folded  on  itself.  The  manner  in  wliicli  tlie  lijanen  is  folded, 
nnder  such  circumstances,  varies  somewhat  in  accordance  with  its  form. 
The  crescentic  hymen  presents  a  median  antero-posterior  fold,  resem- 
bling a  raphe ;  the  edge  of  the  circular  hymen  is  folded  in  such  a  way 
as  to  form  the  wrinkled  aj)ex  of  a  cone  directed  externally.  With  wide 
separation  of  the  thighs  and  labia,  these  conditions  are  altered  ;  the  mem- 
brane becomes  more  or  less  tense.  This  is  more  especially  true  in  adults ; 
in  children  separation  of  the  thighs  and  labia  does  not  so  readily  affect  the 
state  of  the  hymen,  because,  in  early  years,  it  is  of  greater  area  than  the 
introitus  vaginae. 

The  presence  of  an  uninjiu-ed  and  intact  hymen  is  in  itself  strong 
presumptive  proof  that  the  normal  and  complete  act  of  coitus  has  never 
taken  place.  Such  a  hjanen  does  not,  however,  exclude,  in  any  case,  the 
possibility  that  partial  penetration,  as  into  the  recess  between  the  labia 
and  into  the  vestibule,  has  taken  place.  Furthermore,  notwithstanding  the 
intact  condition  of  the  hymen,  its  physical  peculiarities  are  of  importance, 
as  has  been  previously  mentioned.  An  uninjured  hymen  might  exhibit 
such  a  marked  degree  of  elasticity  as  to  raise  the  question  of  its  possible 
distention  without  rupture  in  the  act  of  coitus.  Again,  the  size  of  the 
hymeneal  orifice  might  have  some  bearing  upon  this  point :  an  opening 
unusually  large  would  require  less  elasticity  in  the  narrow  membrane  to 
permit  penetration  by  the  male  organ  without  rupture ;  an  opening  of 
small  diameter  would  speak  against  the  possibility  of  complete  penetra- 
tion without  rupture,  notwithstanding  marked  elasticity  of  the  hymen. 
Of  coiu'se,  in  all  questions  on  these  points  the  size  of  the  male  organ  must 
be  considered. 


Fig.  76.— Ruptured  crescentic  bymen,  with  two    Fig. 77. 
lateral  lascerations.    (After  Hofrnann.) 


-Circular  hymen,  torn  in  several  places. 
(After  Hofrnann.) 


As  a  rule  the  hymen  is  torn  more  or  less  in  the  first  act  of  coitus. 
The  resulting  lacerations  of  the  membrane  vary  in  character,  in  part 
owing  to  the  variations  in  its  form  and  structural  character.     Usually 


^EXi'JL    CIUMJ-JS. 


533 


i^7^"c:^i-^ 


sui'li  lacerations  start  from  the  free  margin  of  the  hymen  and  extend 
through  the  memhrniie  to  its  jnnetion  with  the  vaginal  tissn(\s.  Usually 
the  labiated  hymen  is  found  torn  posteriorly  in  the  median  line,  the  tear 
dividing'  the  hymen  into  two  perfectly  distiuct  lateral  valves.  The  cres- 
centic  hymen  commonly  tears  on  each  side  in  snch  a  way  as  to  leave  an 
approximately  triangular  median  valve  attached  along  the  posterior  edge 
of  the  vaginal  entrance.  (Fig*.  70.)  The  circnlar  or  annular  hymen  tears  in 
four  or  more  places,  dividing-  the  hymen  into  several  valvidar  remnants, 
(Fig.77.)  Th(^  structure  (»f  the  hymen  may  determine  departures  from  these 
rules.  Relative  weakness  of  one  part  may  inllnen(;e  the  direction  and 
extent  of  the  laceration.  The 
hymen  sa'ptus  is  peculiar  in  this 
respect,  that  laceration  of  hnt 
one  side  may  take  place,  the  sep- 
tnm  and  opposite  side  remaining 
intact. 

In  recent  cases  it  cannot  be 
difficult  to  recognize  that  rup- 
ture of  the  hymen  has  taken 
place.  There  Avill  he  the  his- 
tor}'  of  hemorrhage,  and  perhaps 
the  evidences  of  it.  The  mem- 
brane will  present  the  unhealed 
edges  of  the  lacerations  ;  and  the 
r(Mnaiuing  tissue  of  the  hjanen 
will  prol>ably  show  some  degree 
of  inflammatory  hypertemia  and 
swelling.  As  a  rule  hemorrhage 
is  insigniflcant  where  the  lacera- 
tion is  confined  to  the  hymen 
itself,  but  it  may  be,  as  ali-eady 
mentioned,  so  considerable  as  to 
call  for  surgical  interference. 
Profuse  hemorrhage  following  a  first  coitus,  or,  more  especially,  an  at- 
tempt at  rape,  is  usually  due  to  laceration  of  other  parts  than  the  hymen, 
either  du-ectly  or  by.  extension  of  the  laceration  of  the  hymen  into  the 
vaginal  wall. 

Repair  of  the  ordinary  lacerations  of  the  hymen  takes  place  in  two  or 
three  days,  but  the  sevei-er  and  more  extensive  tears  may  require  a  con- 
siderable period  to  complete  healing.  The  presence  of  inflannnatory  red- 
ness and  swelling  and  exudation  about  the  edges  of  the  w<mnds  of  the 
hymen  nuikes  the  diagnosis  of  recent  h^'meneal  rupture  easy.  To  i-ecog- 
nize  that  the  hymen  has  at  one  time  been  lacerated,  after  i-epair  lias  been 
completed,  is  much  more  difficult  in  some  cases.  If  the  laceratimi  has 
been  extensive,  with  consequent  imperfecticui  of  repair,  tlie  case  presents 
no  difficidty.  It  is  otherwise,  however,  where  the  lacerations  Inu'e  involved 
merely  the  free  edge  of  the  hymen.  In  such  a  case  repair  may  have 
left  nothing  more  than  slight  notching  of  the  margin  of  the  mendjrane, 
and  very  careful  examination  may  be  necessary  to  differentiate  between 
cicatricial  and  natural  notching  of  the  free  edge  of  the  membrane. 
Marked  cicatrices  result  only  where  the  laceration  has  been  consider- 
able.    The  slighter  artificial  notchinu'  mav  be  distinguished  from  that 


Fig.  78. — Ruptured  hymen  sseptiis  (after 
Hofmiiim). 


534  A   SYSTEM  OF  LEGAL  MEDICINE. 

noraially  present  in  some  cases  by  the  superficial  deficiency  of  tlie  mu- 
cous meml3rane ;  by  the  peculiarity  of  the  outline  of  the  edge  of  the 
notches,  irregularity  being  characteristic  of  those  due  to  laceration ;  and 
by  the  j)reseuce  of  cicatricial  tissue.  The  examination  of  the  hymen  for 
laceration  must  be  very  carefully  conducted,  especially  in  childi-en,  with 
a  \'iew  to  the  avoidance  of  injmy  to  it  at  the  hands  of  the  examiner ;  for 
an  injury  inflicted  in  this  way  might  mislead  at  a  subsequent  examination. 

Coitus,  though  the  commonest,  is  but  one  of  many  ways  in  which 
injury  of  the  hjanen  may  originate ;  and  in  any  case  it  may  become  im- 
portant to  exclude  or  establish  the  influence  of  other  causes  than  coitus 
to  which  an  existing  injury  of  the  hymen  might  be  attributable.  Injury 
of  the  hymen  by  forcible  separation  of  the  thighs  is  scarcely  possible, 
save  as  a  feature  of  a  laceration  of  the  perineal  structiu-es,  which  could 
oecm'  only  as  the  resiilt  of  force  sufficient  to  accomplisli  dismemberment. 
In  childi'en  the  most  extreme  separation  of  the  thighs  compatible  with 
integrity  of  the  limbs  and  perineum  would  still  have  no  lacerating  effect 
on  the  hjTnen,  omng  to  the  fact  that  the  infantile  hymen  is  of  greater  ex- 
tent than  the  dilated  introitus  vaginae.  Falls  on  the  perineum,  with  im- 
pact upon  objects  capable  of  exerting  localized  pressure  and  partial  pene- 
tration dii-ectly  between  the  lal)ia,  or  of  di-iving  the  soft  parts  upward  into 
the  pelvic  outlet,  might  lacerate  the  hpnen ;  but  isolated  rupture  of  the 
hpnen  by  accident  of  this  nature  would  lie  possible  only  under  most  pecul- 
iar circumstances.  It  is  thought  that  the  practice  of  mastui'bation  com- 
monly leads  to  injuiy  or  alteration  of  the  hj-men ;  this  may  be  true  in 
3"outliful  and  matui-e  females,  but  quite  the  contrary  is  the  fact  in  the 
«ase  of  young  cliildi-en.  Undoubtedly  manustupration  is  a  very  common 
practice  among  female  children,  as  it  is  among  boys ;  but  the  manipula- 
tions are  usiially  confined  to  friction  and  titillation  of  the  clitoris  and 
inner  sm-f aces  of'  the  labia.  These  parts  early  have  an  erogenous  power, 
while  the  introitus  vagina  and  other  parts  do  not  become  erogenous  until 
quite  late ;  not  until  puberty,  and  in  some  cases  not  until  after  the  first 
act  of  coitus.  In  children  it  is  common  to  find  that  attempts  have 
been  made  to  pass  objects  into  the  lu-ethra.  In  case  the  finger  or  other 
objects  have  been  passed  into  the  vagina,  the  insertion  has  been  gradu- 
ally accomplished  and  the  hjaneneal  orifice  dilated  rather  than  the  mem- 
brane ruptiu'ed.  Primtus  from  any  cause  in  childi'en  might  occasion 
so  severe  rubbing  and  scratching  as  to  lead  to  injurj^  of  the  hymen.  TLis 
is  a  more  fi-equent  cause  of  injmy  to  the  lij-men  in  cMldi-en  than  simple 
manustupration.  Cicatrices  may  be  found  on  the  hjmien  that  have 
resid-ted  from  disease-processes  like  diphtheria,  noma,  and  smallpox; 
but  in  such  cases  the  character  of  the  scars  and  the  history  "wdll  usually 
make  the  diagnosis  of  theii-  nature  easy.  Venereal  disease  may  also 
give  rise  to  cicatrices  on  the  hymen,  and  that  too  when  no  rupture  of 
the  membrane  has  taken  place. 

The  first  coitus  may  occasion  injury  of  other  parts  besides  the  hymen. 
The  f ourchette  is,  -svith  the  hymen,  the  part  most  frequently  involved ; 
but  laceration  of  the  njonphge  and  even  rupture  of  the  perineum  have 
been  known  to  result  from  it.  However,  such  injuries  are  uniisual,  and 
o.ould  but  seldom  be  caused  by  simjjle  coitus  in  a  fuUy  developed  femaje. 
In  children  it  is  otherwise.  Forcible  penetration  of  the  adult  male 
organ  into  the  vagina  of  a  child  or  immature  girl  might  cause  rupture  of 
the  fourchette,  the  peiineum,  and  even  the  vagina.     The  cases  reported 


SEXUAL   CRIMES.  5;j5 

in  wliich  such  extensive  injury  was  inflicted  are,  for  the  most  part,  tliose 
of  cliikh'eii  under  the  age  of  fourteen.  Wliere  such  extensive  lacci-a- 
tious  are  present,  especially  in  mature  females,  tliei-e  is  always  gi-cat 
probability  that  they  have  been  l)rought  aljout  by  other  means  than  the 
penis.  Insertion  of  the  finger  is  capable  of  occasioning  rui)ture  of  the 
hymen  like  that  due  to  penetration  of  the  penis,  but  the  finger  may 
inflict  much  greater  injiuy  than  the  male  organ,  if  used  with  any  great 
force  or  misdirection.  Laceration  of  other  parts  than  the  h^anen,  even 
in  small  children,  is  more  frequently  due  t(^  attemjjts  at  manual  dilata- 
tion on  the  part  of  the  ra})ist  than  to  forcil)le  attempts  to  introrluce  the 
penis.  Injur}'  of  the  vestibule  and  urethra,  under  such  circumstances, 
is  almost  invariably  due  to  manual  effort. 

Tlie  .'<fafe  of  f/ie  rmjinal  loall  and  iiikcohs  memhrane  in  tlunnselves  in 
mature  fenuiles,  aside  from  gross  injury,  can  afford  no  evidence  as  to 
whether  primary  coitus  has  taken  place  or  not;  in  children,  however, 
the  vaginal  passage,  which  is  narrow,  may,  after  distention  by  an  adult 
penis,  present  evidence  of  its  having  been  dilated.  On  the  other  hand, 
habitual  repetition  of  the  act  of  coitus  does  induce  quite  characteristic 
alterations  of  the  vagina ;  it  loses  the  folds  characteristic  of  its  virgin 
.state,  and  the  mucous  membrane  loses  its  primitive  delicacy  of  structure  ; 
and  the  tissues  and  muscles  about  the  introitus  vagina?  become  relaxed. 
These  changes,  secondary  to  repeated  coitus  and  labor,  are  of  interest 
here  only  as  circumstances  which  render  impossible  anj^thing  like  ana- 
tomical evidence  of  the  single  act  of  normal  coitus. 

Proof  of  the  presence  of  semen  in  or  about  the  genitals  of  the  female,  or 
on  her  clothing,  may  be  of  great  importance  in  some  cases  of  alleged  rape. 
The  secretions  found  in  the  vagina  and  uterus  a  short  time  after  the 
alleged  perpetration  of  rape  may  afford  incontestible  proof  of  sexual 
c<mtact.  For  purposes  of  examination,  a  small  quantity  of  the  secretions 
should  be  taken  from  the  parts  and  preserved  between  glass  slides  or 
otherwise  for  microscopical  examination.  Dried  secretions  found  on  the 
external  genitals  or  genital  hair  may  afford  the  same  proof  of  male  con- 
tact or  proximity.  Such  dried  secretions  shoidd  be  carefully  scraped 
from  the  parts,  or  removed  by  severing  the  hair  to  which  they  are  found 
attached,  and  carefully  preserved.  Stains  found  upon  the  linen  should 
also  be  taken  for  microscopic  examination.  Stains  may  be  preserved  for 
examination  by  cutting  out  the  parts  of  the  garments  that  present 
them.  When  possible,  such  specimens  should  l)e  submitted  to  an  expert 
microscopist  for  examination  and  report ;  but  it  may  be  necessary  for 
the  examining  physician  to  give  his  opinion  upon  the  nature  of  such 
findings. 

The  only  distinctly  characteristic  constituent  of  semen  is  the  sper- 
matozo(hi :  all  other  organic  bodies  found  in  the  seminal  fluid  are  of  too 
little  definiteness  of  form  to  permit  a  just  conclusion  as  to  the  nature 
of  a  specimen  in  which  spermatozoa  are  not  found.  On  the  other  hand, 
failure  to  find  spermatozoa  in  suspected  fluid  or  stains  is  not  proof  that 
they  are  not  of  seminal  origin.  Spermatozoa  are  not  infretiuently  ab- 
sent from  the  senum  of  men  given  to  sexual  excesses,  and  of  those  that 
have  suffered  with  epididymitis. 

The  examination  of  a  fluid  suspected  to  contain  spermatozoa  is  sim- 
ple. A  drop  of  the  fluid  placed  on  a  glass  slide  is  covered  with  a  c<n"er- 
glass  and  examined  through  a  lens  of  high  power.     If  the  specimen 


536  -i  SYSTi:2i  OF  legal  medicixe. 

contrtia  liAiug  spermatozoa  thev  "vrill  be  seen  mo^TLng  about  iu  the  fielil 
as  cell-like  objects,  tlie  tail-like  processes,  owing  to  theii-  rapid  \-ibratory 
movement,  being  all  but  in^dsible.  TMien  the  spermatozoa  are  lifeless 
the  processes  are  readily  distinguished.  To  prepare  a  specimen  of  dried 
secretions  for  examination,  a  drop  of  distilled  "^vater  is  placed  on  a  glass- 
slide  and  a  pai-ticle  of  the  diied  matter  dropped  in  it.  As  the  particle 
imbibes  "water  it  should  be  gently  teased  -with  needles  until  it  is  quite 
broken  up  and  diffused.  Covered  "with  a  glass,  the  specimen  is  then 
ready  for  examination.  For  examination  of  a  stain  on  linen,  a  portion 
of  the  stained  faliric  should  be  soaked  in  a  di-oj)  or  two  of  distilled  "water, 
and  the  resulting  solution  may  then  be  examined  in  the  manner  de- 
scribed. It  is  remarkable  how  long,  iinder  favoring  ch"cumstances,  sperm- 
atozoa retain  their  characteristic  form.  They  have  been  demonstrated 
in  secretions  that  have  remained  desiccated  many  months,  even  years. 
Water  C[uickly  kills  spermatozoa;  therefore,  to  demonstrate  theu-  com- 
paratively recent  deposition  in  the  female  genitals  by  finding  them  active, 
it  is  necessary  to  examine  secretions  almost  immediately  after  their  re- 
moval, and  that  "without  the  addition  of  "water  to  them.  Formerly  certain 
peculiarities  of  seminal  stains  "were  held  to  be  characteristic  -,  but  theii" 
presence  could  establish  nothing  more  than  a  presmnp^ion  that  the  stains- 
"were  of  seminal  origin  in  the  al^sence  of  microscopic  demonstration.* 

Venereal  disease  fi-equently  plays  an  important  jDart  in  cases  of  alleged 
rape,  as  e-sadence  that  sexual  contact  or  coitus  has  taken  place.  In  a 
medico-legal  case  where  the  cxuestion  of  the  existence  of  venereal  disease  in 
the  plaintiff  calls  for  an  answer,  the  gTeatest  care  and  accuracy  in  diagnosis 
are  demanded  of  the  medical  "witness  called  uj)on  to  answer  the  cj^uestion. 
Fortunately,  in  the  case  of  gonorrhea,  the  bacteriological  examination 
is  capable  of  gi"^'ing  positive  e-^ddeuce  of  the  nature  of  a  genital  dischaig-e 
in  certain  cases.  The  gonococcus,  when  found,  is  an  absolute  demon- 
stration of  the  venereal  natiu-e  of  a  genital  catarrh ;  its  absence,  or  fail- 
ure to  find  it,  however,  does  not  constitute  negative  e"^-idence  of  like 
value.  It  is  mainly  in  the  acute  stage  of  gonorrhea  that  the  presence  of 
the  gonococcus  is  easily  demonstrable  in  the  discharge.  At  an  acute 
stage,  it  "will  be  found  in  the  vaginal  secretions,  and,  in  childi-en  espe- 
cially, iu  the  moist  secretion  bathing  the  mucous  siu'faces  of  the  ■\-ulva. 
In  the  chi'onic  stages  of  the  disease  it  is  less  apt  to  be  discovered  in  the 
vaginal  secretion,  but  may  still  be  found  in  the  cer-^ical  mucus,  and  in 
the  secretions  expressed  from  the  lU'ethra,  which  is  the  preferred  habitat 
of  the  specific  microorganism.  What  is  true  of  the  gonococcus  in  the 
female  is  also  applicable  to  the  male.  It  is  found  easily  in  the  dischai-ge 
from  the  male  lu-ethra  dia'ing  the  acute  stage  of  gonorrhea ;  in  a  chi'onic 
stage  its  habitat  is  the  deeper  portion  of  the  urethra,  and  it  is  difficult  to 
demonstrate  its  presence  in  the  gleety  discharge.  With  reference  to  the 
value  of  the  bacteriohjgical  examination  of  discharges  suspected  to  be 
gonorrlieal,  it  may  be  said  that  the  discoveiy  of  the  gonococcus  is  an 
absolute  demonstration  of  the  veuereal  nature  of  a  discharge  ;  that  failure 
to  find  it  in  the  discharge  from  an  acutely  inflamed  genital  siu'face  con- 
stitutes presumptive  e\"idence  that  the  inflammation  is  non-venereal  in 
natm-e ;  that  failure  to  find  it  in  a  discharge  of  a  chronic  character  is  of 
no  value  as  an  aid  in  the  determination  of  the  real  uatiu-e  of  the  disease. 

*  Cf.  Seminal  Stains,  vol.  i.,  p.  184. 


SEXUAL    CRIMES.  537 

'There  is  iieitlier  spa(;e  nor  need  here  to  ^ive  the  teehnieal  details  of  tlie 
baeteriologieal  examination  for  the  determination  of  tlie  .speeiiie  nature 
of  discharges  ;  sueh  an  examination,  for  medico-legal  purposes,  must  needs 
be  made  by  an  expert  bacteriologist. 

The  necessity  for  accurate  determination  of  the  nature  of  a  malady 
affecting  the  female  genitals  is  shown  especially  in  those  cases  where 
the  existence  of  the  disease  constitutes  the  Ijasis  for  the  institution  of 
criniiual  pro(teedings ;  and  such  cases  have  not  been  rare,  especially  in 
Europe.  There  is  a  belief  mcn'e  or  less  prevalent  among  some  of  the 
more  ignorant  peasantry  of  Europe  that  ol)stinate  gonorrhea  in  the  male 
is  to  be  cured  by  sexual  intercourse  with  a  ^'irgin — hence,  with  a  child. 
This  leads,  not  infrequent!}",  to  the  allegation  that  a  simple  vaginal 
catarrh  in  a  child  is  the  resiilt  of  infection  at  the  hands  of  some  infected 
male.  Such  a  belief  is  nowhere  prevalent  in  the  United  States ;  but, 
owing  to  the  immigration  of  the  peasant  classes  of  Europe,  the  possible 
oper;ition  of  such  au  idea  in  the  production  of  sexual  assault  on  children, 
and  in  the  preferment  of  charges  of  rape,  based  upon  simple  genital 
disease  in  them,  should  be  kept  in  mind. 

Important  as  the  proof  of  venereal  disease  is  as  an  evidence  of  sexual 
contact,  it  is  never  of  absolute  value  in  itself.  The  genitals  may  become 
infected  with  venereal  disease  in  many  other  waj'S.  A  case*  is  on  record 
where  two  female  children  were  infected  with  gonorrhea  by  means  of  a 
sponge  used  in  the  bath,  the  sponge  having  been  previous^  used  by  a 
man  suffering  w^ith  the  disease.  G-euital  infection  might  be  brought 
about  Ijy  the  hand  of  au  infected  manustuprator ;  or  a  child  might  in- 
fect its  own  genitals  with  its  own  hands,  after  manipulation  of  the  dis- 
eased genitals  of  another  person.  Again,  one  infected  f enuile  might  infect 
another,  were  mutual  genital  manijDulation,  or  genital  contact,  to  be  prac- 
ticed. The  latter  possibility  Avill  seem  less  improbable  if  it  is  remembered 
that  there  is  a  record  of  the  transference  of  seminal  fluid  from  one  female 
to  another,  resulting  in  the  pregnancy  of  a  woman  who  had  never  known 
male  contact.  It  is  also  conceivable  that  a  female  presenting  signs  of  the 
secondary  stage  of  syphilis  might  make  them  the  basis  of  criminal  accusa- 
tion. With  syphilis,  as  with  gonorrhea,  the  possibilities  of  infection  are 
not  exclusively  genital.  Kissing  is  a  very  frequent  manner  of  communi- 
cating the  disease ;  and  genital  osculation,  or  cuuniliugus,  is  another 
possible  source  of  genital  infection. 

A  genital  discharge  due  to  simple  inflammation  of  some  portion 
of  tlie  genito-urinary  tract  of  females,  both  adults  and  children,  may 
be  due  to  a  variety  of  causes.  It  is  very  connuon  for  the  virgin  to 
have  a  simple  leucorrhea ;  and  the  existence  of  it  may  predispose 
to  the  development  of  an  intense  muco-purulent  inflammation  im- 
mediately upon  the  performance  of  the  first  coitus ;  and  that  without 
specific  infection  of  any  kind.  This  possibility  is  capable  of  raising 
more  than  one  important  medico-legal  question.  A  bride  has  been 
known  to  sue  for  divorce  on  the  ground  that  she  had  been  infected  by 
her  newly  made  husband,  when  the  disease  was  due  only  to  the  mechan- 
ical irritation  of  the  first  coitus.  Again,  in  fenuiles  that  have  been 
raped,  it  is  common  to  find  such  a  non-specific  discharge  from  the  genitals 
when  thc}^  are  examined  shortly  after  the  crime  ;  and  it  is  important  not 

*  Ryan,  eited  by  Hdfmaini,  GcrichtJh'hc  Med.,  y>.  137. 


538  -i  systjEM  of  legal  medicine. 

to  mistake  this  for  gouorrliea.  For  gonorrhea  may  not  be  found  in  the- 
alleged  ravisher,  and  thus  a  false  ground  for  defense  might  be  established. 
Among  the  more  common  causes  of  muco-purulent  genital  discharges 
in  females  are  disordered  menstruation ;  masturbation,  however  prac- 
ticed ;  skin  diseases ;  oxyiuis  vermicularis,  alone  or  in  conjunction  with 
manual  irritation.  Genital  catarrh  may  also  be  an  accompaniment  of  a 
general  enfeebled  state  of  the  organism,  as  in  tuberculosis  and  chlorosis. 
Vulvo-vaginal  catarrh  sometimes  occurs  in  an  epidemic  form.  The  pos- 
sibility of  diphtheritic  uiilammation  of  the  genital  mucous  membrane  is 
also  to  be  remembered. 

The  close  resemblance  of  venereal  inflammation  to  simple  inflamma- 
tion of  the  genital  mucous  membrane  has  led  designing  mothers  to 
excite  the  latter  in  their  young  daughters,  by  mechanical  means,  for  the 
j)urpose  of  blackmail  or  revenge. 

In  a  given  case  it  may  become  essential  to  determine  the  relation  be- 
tween the  alleged  tune  of  infection  with  s]3eciiic  venereal  disease  and  the 
stage  of  the  malady  indicated  by  conditions  found  upon  examination.  It  is 
necessary,  therefore,  to  consider  the  periods  of  incubation  more  or  less 
characteristic  of  such  affections.  Great  care  must  be  exercised  in  gi\iug 
medico-legal  opinions  concerning  ulcerative  processes  affecting  the  female 
genitals.  The  differentiation  of  such  j)rocesses  from  sj^phUitic  sores 
does  not  present  much  difficulty ;  but  errors  maybe  made  if  it  is  not  remem- 
bered that  ulcers  of  other  kinds  may  simulate  the  hard  chancre,  owing  to 
some  induration  of  their  bases ;  that  syphilitic  induration  is  not  always 
tj^Dical.  The  diagnosis  is  not  to  be  made  until  after  thorough  considera- 
tion of  all  the  e\ddence.  The  diagnosis  of  soft  chancre  is  to  be  made  more 
especially  from  its  coiu'se  than  from  its  character  and  seat.  To  be  sure, 
soft  chancre  can  be  diagnosticated  by  inoculation  on  the  person  affected, 
but  such  a  means  will  rarely  be  expedient.  It  may  be  necessary  to  distin- 
guish soft  chancre  from  herpes.  Ulcerative  and  gangrenous  processes 
of  various  kinds  affecting  the  genitals  may  be  mistaken  for  venereal  affec- 
tions ;  more  especially  noma  and  diphtheritic  ulceration,  which  sometimes 
affect  the  genitals  of  female  children  after  scarlet  fever,  t^^phoid  fever, 
and  measles.  For  the  expression  of  a  medico-legal  oiDinion  in  cases  where 
the  question  of  venereal  disease  is  a  matter  for  decision,  it  will  be  seen 
that  a  thorough  acquaintance  Avith  all  the  characteristics  of  the  venereal 
affections  is  essential ;  however,  such  knowledge  is  to  be  gained  best  in 
works  devoted  speciall}^  to  them,  and  it  does  not  fall  properly  within 
the  scope  of  this  article  to  enumerate  diagnostic  criteria. 

In  any  case  where  the  existence  of  venereal  disease  is  accessory  evi- 
dence of  rape,  examination  of  the  person  of  the  accused  will  give  addi- 
tional evidence  of  gi-eat  importance.  It  is  impossible  to  do  this,  how- 
ever, mthout  the  consent  of  the  accused.  The  presence  of  similar  disease 
in  the  j^erson  accused  becomes  strong  cii'cumstantial  eAddence  against 
him.  It  is  to  be  remembered  how  chronic  gonorrhea  in  the  male  may 
easil}^  escape  observation,  and  precautions  are  to  be  taken  to  guard 
against  such  an  error.  The  urethra  is-  to  l^e  examined  some  hours  after 
the  last  act  of  urination.  A  gleet,  while  on  the  whole  less  infectious 
than  a  gonorrhea  in  its  active  stage,  may  infect,  and  that  the  more 
readily  in  case  of  genital  contact  with  virgins  and  children.  On  the- 
other  hand,  the  existence  of  disease  in  the  female  and  its  absence  in  the 
male  accused  is  evidence  of  his  innocence  and  of  her  leM'dness.     StOl,. 


SEXUAL   CRIMES.  ;j;J9 

there  may  be  sexual  eoutaet  iinder  such  ch'cumstances  without  infection. 
However,  a  diseased  i)rostitute  accusing  a  man  of  rape  would  with  diffi- 
culty sustain  her  charge  in  case  the  accused  were  free  from  infection. 
Again,  the  absence  of  disease  in  the  accusing  female  and  its  presence  in 
the  accused  male  would  (n)nstitute  strong  evidence  that  sexual  contact 
had  not  taken  place,  espcicially  were  the  female  a  virgin  or  a  child,  and 
the  disease  gonorrhea;  at  the  same  time,  these  conditions  would  \n)X, 
actually  disi)i'<)ve  sexu.-d  contact. 

The  Physical  Evidences  of  Force. — ►Since  there  can  be  no  rape 
where  there  has  been  no  force,  actual  or  constructive,  it  may  become  the 
duty  of  the  medical  witness  in  a  trial  for  ra})e  to  give  testimony  concern- 
ing tangible  evidence  of  the  use  of  physical  force.  Severe  injiuies,  such 
as  might  result  from  blows,  choking,  l)rutal  violence  to  the  genitals,  etc.^, 
do  not  })resent  any  difficulties;  where  injuries  are  slighter,  the  questiou 
of  their  self-inttiction  l)y  the  alleged  victim  must  be  considered.  Signs 
of  force  may  speak  as  well  for  the  degree  of  resistance  of  the  victim. 
The  old  (piestion  whether  it  is  possible  for  a  single  man  to  force  a  woman 
of  good  physical  development,  while  in  full  possession  of  her  senses,  tO' 
submit  to  coitus,  is  quite  beside  the  mark  in  cases  of  actual  rape.  Un- 
der such  circumstances,  though  a  woman  might  appear  to  be  physically 
capable  of  successfully  resisting  the  sexual  ap^rroacli  of  a  man,  her  failiu'e 
to  do  so  would  be  no  evidence  that  she  had  not  offered  all  the  resistance 
possible  for  her  at  the  time.  Even  though  the  man  were  proportionately 
weaker  than  the  woman  the  same  would  hold  true;  for  the  psychical 
excitement  induced  in  the  woman  by  the  attack  might  l)e  suificient  to 
nudce  her  physical  resistance  less  effectual  than  it  would  otherw^ise  be. 
When  a  woman  is  attacked  by  a  man  with  intent  to  compel  her  sub- 
mission to  coitus,  no  matter  what  her  physical  strength,  the  initial  ener- 
getic resistance  she  .offers  will  probaljly  grow  less  under  the  influence  of 
pain  inflicted  by  the  ravisher  in  his  efforts,  and  as  a  residt  of  the  wom- 
an's psychical  'excitement  and  fear  that  the  greatest  bodily  hai-m  may 
be  inflicted.  "Aie  wonuin's  mental  condition  may,  through  apprehension, 
finally  become  such  as  to  make  physical  resistance  no  longer  possible. 
However,  remembering  the  frequency  with  which  false  charges  of  rape 
are  made,  it  may  become  necessary  to  consider  the  comparative  strength 
of  acicused  and  accuser.  In  case  it  seems  that  the  woman  were  capable 
of  offering  effectual  physical  resistance,  it  is  proper  to  direct  attention 
to  the  discovery  of  conditions  that  may  have  prevented  its  exercise. 

Where  strenuous  resistance  has  been  offered  by  a  woman,  physical 
evidences  of  the  force  used  by  the  man  will  rarely  ])e  wanting;  always 
provided  that  they  are  souglit  before  sufficient  time  has  elapsed  to 
allow  their  renu)val  by  natural  processes.  The  physical  evidences  of 
force  will  be  the  more  obvious  the  more  strenuous  and  long-continued 
resistance  has  been.  Scratches,  bruises,  and  more  serious  injuries  on 
the  person  of  the  woman  nuiy  lie  in  evidence.  These  injuries  may  be 
found  on  almost  any  part  of  the  body,  but  they  are  most  frequently 
seated  on  the  limbs,  es])ecially  the  thighs.  The  external  genitals  often 
present  evidence  of  violent  treatment. 

Some  caution  is  necessary  in  determining  the  nature  of  marks  pre- 
sumed to  be  the  evidence  of  the  infliction  of  violence.  Natural  pigmen- 
tations of  the  skin  have  been  mistaken  for  suggillations.  Self-inflicted 
marks  and  injuries  are  usually  slight,  and  to  be  found  only  on  parts  of 


540  ^   SYSTEM  OF  LEGAL  MEDICINE. 

tlie  person  easily  reaclied  by  the  hands.  The  genitals  are  usnally  the 
parts  chosen  for  injury  by  a  woman  seeking  to  deceive.  In  any  case, 
injuries  presented  as  evidence  of  force  used  in  the  aecompHshment  of 
rape  are  to  be  considered  with  resj)ect  to  the  relations  their  aspect  at  the 
time  of  examination  bears  to  the  time  they  are  asserted  to  have  been 
inflicted.  The  person  of  the  accused  may  also  give  evidence  of  a  physi- 
cal kind  of  the  resistance  offered  by  the  victim.  Scratches,  bruises,  and 
wounds  made  by  biting,  may  be  found.  Injui'ies  of  the  male  genitals 
are  not  unusual. 

Moral  Force. — ^When  coitus  is  accom]3lished  by  means  of  threats  of 
violence,  the  resistance  of  the  female  being  thus  precluded  by  fear,  the 
act  is  none  the  less  rape ;  but  under  such  circumstances  the  e^ddence 
that  resistance  was  thus  obviated  requires  no  medical  interpretation. 
The  threats  used  may  be  directed  against  the  woman's  own  .person  or 
against  others.  Thus,  a  mother  might  be  forced  to  submit  to  coitus  by 
threats  dii-ected  against  her  chrLdi-en.  Resistance  to  sexual  attack  may 
be  prechided  by  23hysical  or  mental  conditions.  A  female  in  an  invalid 
condition  might  be  incapable  of  offering  any  physical  resistance. 

Fraud. — In  law,  intercourse  accomphshed  through  fraud,  without 
intention  to  use  violence,  is  not  rape ;  but  unlawful  connection  with  a 
woman  while  she  is  asleep,  unconscious,  or  insensible  as  a  result  of  in- 
toxication by  alcohol  or  other  narcotics,  is  commonly  rape.  Where  co- 
itus is  accomphshed  upon  a  woman  by  a  man  who  takes  advantage  of 
circumstances — darkness,  etc. — to  have  himself  mistaken  by  her  for  her 
husband,  the  act  is  one  of  fraud ;  and  if  there  were  no  intention  on  the 
part  of  the  man  to  use  violence,  such  a  crime  coidd  not  be  legally  held 
to  be  rape.  At  the  same  time,  a  sense  of  strict  justice  could  but  regard 
such  a  crime  as  much  a  rape  as  coitus  performed  with  a  female  whose 
senses  have  been  befogged  by  intoxicants.  Again,  for  example,  coitus 
performed  by  a  j^hysician  with  a  patient  on  the  pretext  that  the  act  is  a 
necessary  part  of  medical  treatment  is  not  rape,  but  fraud ;  though  it  is 
possible  that  such  a  crime  could  be  made  rape  in  law  by  pro\dng  the 
imbecHitj'  of  the  victim ;  or  her  want  of  adequate  knowledge  of  the 
nature  of  the  act,  if  such  could  be  shown,  shoidd  establish  the  same  de- 
gree of  ii-responsibility  for  consent  that  obtains  in  cases  of  children. 

States  of  Unconsciousness. — It  has  been  a  mooted  question  whether 
coitus  could  be  performed  on  a  female  sleeping  normally  without  awak- 
ening her.  That  such  a  thing  is  possible  must  be  admitted;  but  there 
woidd  needs  be  a  rare  coml>ination  of  circumstances  to  make  the  possi- 
bihty  an  actuality.  A  married  female  might  be  subjected  to  the  sexual 
act  without  rousing  from  slumber;  but  a  female  who  had  never  per- 
formed coitus  would  certainly  be  awakened  from  any  normal  sleep  by 
the  unusual  manipulations  and  pain  necessarily  attendant  upon  the  act. 
Sleep  and  a  favoring  position,  vnth  absence  of  impeding  garments,  might 
make  the  commission  of  rape  easier,  and  permit  the  perpetrator  to  gain 
such  advantage  that  the  female,  on  awaking,  would  find  all  her  resistive 
efforts  f utde. 

States  of  unconsciousness  differing  from  that  of  normal  sleep,  in  that 
they  are  deeper  and  less  easily  overcome,  may  be  used  as  aids  in  the 
performance  of  unlawfid  coitus.  Such  unconscious  conditions  may  be 
purposely  induced  for  an  ultimate  sexual  object ;  or  being  present,  they 
may  be  utiUzed  for  such  a  purpose.     A  woman  might  be  purposely  in- 


SEXUAL   CRIMES.  541 

dueed  to  take  alcohol  to  intoxication,  and  lier  condition  utilized  for  a 
sexual  purpose.  If,  while  intoxicated  in  this  way,  a  woman  still  offered 
resistance  to  the  sexual  ai)proacli,  or  if  she  were  so  far  unconscious  as  to 
know  or  remember  nothin<>-  of  the  act,  the  crime  woidd  be  rajjc.  How- 
ever, if  under  such  cu'cumstances  a  woman  were  to  give  consent,  the 
criminal  sexual  act  would  not  be  rape,  notwithstanding  the  contributing 
effect  of  the  intoxi(^ant,  unless  unconsciousness  of  the  acquiescence  could 
be  proved.  In  such  a  case,  where  an  adult  female  is  concerned,  it  would 
be  assumed  that  she  wei-e  more  or  less  acquaintt'd  with  the  effects  of 
alcohol,  and  that  she  knowingly  took  that  which  would  lower  her  moi'al 
resistive  power.  With  a  youthful  fenuxle  unaccpiainted  with  the  effects 
of  alcohol  in  the  ordinary  forms  in  which  it  is  taken,  the  case  would  Ijc 
quite  different ;  and  consent  under  such  circumstances  might  not,  or 
shoidd  not,  qualify  the  crime. 

Other  narcotics  might  be  purposely  or  secretly  administered  for  the 
purpose  of  removing  the  possibility  of  resistance  to  sexual  approaches. 
The  most  important  of  these  are  chloroform,  ether,  nitrous  oxide,  opium 
and  its  alkaloids,  and  cliloral  hydi-ate ;  but  there  ai'e  many  other  sub- 
stances that  might  eventually  be  used  to  serve  such  a  purpose.  There 
are  but  veiy  few  cases  on  re(;ord  in  which  the  more  powerful  narcotics 
and  ana?sthetics  have  been  used  primarily  mth  the  purpose  to  induce  a 
■condition  that  would  render  resistance  to  coitus  impossible;  but  there 
have  been  numerous  instances  in  which  the  effects  of  these  agents  hav- 
ing been  induced  for  other  purposes,  the  opportunity  has  been  used  for 
sexual  approach.  This  is  especially  true  of  anaesthetics  administered  for 
surgical  procedures.  Not  infrequently  the  complaint  is  made  that  un- 
consciousness has  been  suddenly  induced  by  the  sudden  and  unexpected 
use  of  chloroform  or  similar  agents.  Such  statements  are  to  be  accepted 
only  with  the  greatest  caution ;  for  such  substances  do  not  produce  im- 
mediate unconsciousness. 

The  question  of  the  possibihty  of  chlorofornnng  a  sleeping  person 
without  disturbing  the  slumber  may  call  for  au  answer.  Experunenta- 
tion  to  test  this  pi'oblem  has  shown  that  it  is  possible  to  induce  ant^s- 
thesia  with  chloroform  without  interrupting  normal  sleep ;  Init  to  do 
this  successfull}',  knowledge  of  chloroform  and  skill  in  its  adndnistra- 
tion  are  required ;  and  even  with  e^^ery  scientific  precaution  the  chance 
of  failure  is  as  good  as  that  of  success.  Therefore,  the  probabilitit's  are 
much  against  the  success  of  an  attempt  by  an  unskilled  operator  to 
•chloroform  a  sleeping  person  without  breaking  the  sleep.  Where  other 
narcotics  are  in  question,  an  appeal  to  known  physiological  actions  will 
•often  prove  valuable  in  determining  the  nature  of  testimony. 

Other  states  of  temporary  unconsciousness  seldom  aff'ord  o])portmiity 
for  sexual  approach.  Maschka  records  the  case  of  an  eiiileptic  girl  who 
accused  a  num  of  having  had  sexual  intercourse  with  her  while  she  was 
unconscious  after  a  seizui-e ;  but  the  details  slu'  gave  of  the  events  that 
took  place  during  her  unconsciousness  were  sultieient  to  invalidate  her 
testinumy. 

Ilijpnosis  might  be  used  as  a  means  to  prevent  resistance  to  sexual 
approach ;  but  aU  cases  in  which  accusations  are  made  upon  this  basis 
should  be  scrutinized  with  the  greatest  caution.  In  such  a  case,  it  may 
not  be  difficult  to  prove  that  the  fenude  is  amenaT)le  or  not  to  hypnosis, 
•or  to  detect  malingering ;  but  it  may  be  impossible  to  show  that  she  was 


542  -^   SYSTi:2I  OF  LEGAL  MEDICINE. 

in  an  li}-[motic  state  at  the  time  of  tlie  alleged  sexnal  assault.  In  the 
cases  of  this  kind  thus  far  reijorted,  the  females  have  been  invariably 
hj'Sterical.  Again,  the  h;yT^)notic  state  is  in  itself  an  abnormal  state  of 
consciousness,  and  any  statements  based  upon  perceptions  of  events 
had  dm-iug  such  a  condition  should  be  accepted  only  with  a  full  under- 
standing of  that  fact.  The  h^^Duotic  state  is  one  preeminently  hallu- 
cinator}-,  and  therefore  prone  to  originate  false  ideas,  especially  iu  the 
hysterical  subject.  For  this  reason,  "there  can  be  no  excuse  for  the  in- 
duction of  the  hj-pnotic  state  in  a  female  by  a  man  mthout  the  presence 
of  witnesses. 

Certain  autohj-pnotic  or  cataleiDtic  states  that  sometimes  occur  in 
hysterical  females  might  be  used  for  sexual  pnrposes ;  but  here,  as  in 
states  of  hj^^nosis  induced  by  a  second  person,  testimony  given  by  the 
subject  should  be  corroborated  by  more  objective  evidence  than  alleged 
perceptions  of  events  during  such  an  abnormal  state  of  consciousness. 

False  Accusations. — Women  frequently  accuse  physicians  and  den- 
tists of  ha^-ing  taken  improper  hl^erties  with  tliem  while  under  the  influence 
of  an  anEesthetic.  Experience  teaches  that  such  accusations  are  to  be  taken 
only  with  the  gTeatest  caution.  In  the  majority  of  such  cases,  the  state- 
ments are  the  outcome  of  iQusions  or  hallucinations  to  which  the  female 
was  subject  dm*uig  the  period  of  temporary  unconsciousness.  Usually 
the_  alleged  victim  asserts  that  unconsciousness  was  incomplete ;  that 
while  robbed  of  all  power  to  make  any  resistance,  there  was  still  con- 
sciousness of  aU  that  was  taking  place.  T\Tiere  testimony  of  this  char- 
acter is  offered,  it  should  never  be  given  weight  mthout  other  independent 
evidence ;  for  it  is  testimony  coneerniug  events  confessedly  experienced 
or  observed  during  an  abnormal  state  of  consciousness.  This  consider- 
ation alone  should  be  sufficient  to  exclude  it  as  trustworthy  testimony. 
The  best  proof  of  the  justification  of  this  position  with  regard  to  such 
testimony  is  offered  by  the  numerous  cases  in  which  such  a,ccusations 
have  been  made  in  the  face  of  the  contrary  testimony  of  other  persons 
who  were  present  at  the  time  of  the  alleged  sexual  assault— even  of  the 
parents  of  the  accusing  female.  In  the  face  of  the  frequency  with  which 
such  accusations  are  made,  no  cii-cumstances  can  justify  the  administration 
of  an  anaesthetic  to  a  female  by  a  physician  ^^dthout  the  presence  of 
others. 

Accusations  of  a  sexual  natm-e  against  physicians  and  others  are 
frequently  made  as  a  result  of  more  obvious  mental  anomahes  in  the 
accusers ;  Ixit  in  such  cases,  the  very  nature  of  the  accusations,  with 
other  evidences  of  mental  disturbance,  are  usually  sufficient  to  establish 
their_  true  character.  Designing  females  have  taken  advantage  of  the 
physician  for  pui-poses  of  blackmail,  by  lodging  accusations  of  improper 
relations  at  times  of  consultation  in  the  absence  of  mtnesses.  The  fre- 
quent necessity  for  unwitnessed  couference  between  physician  and  patient 
affords  excellent  opportunity  for  a  designing  woman. "  The  possibility  of 
troiiljle  of  this  kind  is  so  great  that  the  physician  jealous  of  his  repu- 
tation cannot  afford  to  take  risks,  more  especially  in  the  practice  of 
gynecology ;  it  is  his  duty  to  himself,  as  to  his  patient,  to  have  a  female 
witness  at  hand  in  aU  cases  of  genital  examination,  etc. 

False  accusations  founded  upon  genital  disease  in  children,  and  upon 
such  disease  induced  for  the  purpose  of  blackmail,  have  been  abeady 
alluded  to  in  preceding  pages. 


SEXUAL   CHIMES.  543 

states  of  Non  Compos  Mentis. — Unlawful  intercourse  with  a  female 
idiot  or  imbecile,  or  with  an  insane  female,  is  commonly  rape.  In  such 
a  case  resistance  and  force  may  have  been  in  play,  as  in  any  other ;  but, 
under  such  circumstances,  ordinaril}'  the  question  of  the  crime  of  rape 
hangs  upon  tlie  irresponsibility  of  the  female  for  the  assent  she  may 
have  accorded.  The  proof  of  the  mental  condition  of  the  prosecutrix 
then  becomes  indispensable ;  and  this  must  follow  on  general  psychi- 
atrical lines.  At  the  same  time,  in  case  consent  has  been  given  by  an 
irresponsiljle  female,  it  would  also  be  oljligatory  on  the  part  of  the 
prosecmtion  to  show  that  the  accused  was  aware  of  the  irresponsibility 
of  the  female,  in  order  to  bring  the  crime  within  the  legal  definition  of 
rape. 

Actual  and  Apparent  Age. — Sexual  intercourse  with  a  female  under 
the  age  of  consent  is,  under  all  circumstances,  rape.  It  would  seem,  liow- 
ever,  that  where  the  age  of  consent  is  high  (fourteen  years)  there  might 
be  conditions  which  would  mitigate  the  crime.  Though  under  the  age 
of  consent,  a  girl  might  be  so  fully  developed  as  to  make  her  appear 
much  older ;  and  her  consent  to  a  sexual  approach,  or  invitation  of  one, 
should  then,  in  the  ignorance  of  the  man,  be  given  the  weight  of  the 
consent  of  one  of  the  age  which  she  appears.  Such  a  case  is  considered 
by  the  Austrian  law. 

Sexual  Assault  of  Children. — Rape  of  children  is  the  most  frequent 
form  of  sexual  crime.  The  majority  of  children  thus  abused  are  of  tender 
years ;  even  babyhood  is  not  exempt.  The  age  in  recorded  cases  ranges 
from  eight  months  upward.  There  are  no  statistics  shomng  the  num- 
ber of  cases  of  rape  and  the  proportion  of  children  concerned  in  America, 
but  statistics  show  that  in  France  from  1851  to  1875  inclusive  there  were 
22,017  cases  of  rape  brought  to  trial.  Of  this  uumber,  but  -loGO  con- 
cerned adult  females  ;  the  remainder,  children.  (Tardieu.)  Of  406  cases 
of  alleged  rape  examined  by  Casper  and  Liman,  84  percent,  of  the 
females  were  under  the  age  of  fourteen,  and  70  percent,  below  the  age 
of  twelve ;  and  in  248  cases  reported  by  Maschka,  the  age  was  below 
fourteen  in  171  instances. 

It  is  but  natural  to  seek  soem  reason  for  the  great  j)reponderance 
of  such  sexual  assaults  of  children.  The  superstitious  ignorance  which 
fosters  a  belief  that  gonorrhea  is  cured  by  intercourse  with  a  vii'gin  or 
child  would  have  an  influence  to  increase  sexual  assaults  on  children 
where  it  prevailed.  Many  times  children  are  approached  because  they 
can  be  persuaded  more  readily  than  others  to  sulmiit  to  embraces  of  the 
nature  of  which  they  ai'e  ignorant ;  or  because,  if  need  be,  their  i-esi st- 
ance can  be  easily  overcome.  Similarly,  old  women  may  become  victims 
by  reason  of  their  presumed  lack  of  power  to  offer  physical  resistance. 
In  some  instances  children  fall  victims  to  men  who  have  not  the  courage 
(fear  of  impotence)  to  attempt  intercourse  with  adult  females.  Througli 
fear  of  possible  failure  with  an  adidt,  and  consequent  ridicule,  a  young 
man  may  first  essay  sexual  contact  with  a  child.  Intercourse  may  be 
attempted  mth  a  child  with  the  thought  to  seek  a  new  stimulus  to  sexual 
power  exhausted  in  sexual  debauchery  with  women.  Sexual  assaults 
upon  children  by  aged  men  are  especially  frequent.  In  such  cases,  in 
the  male  there  is  usually  a  coincidence  of  impotence  and  libido :  sexual 
desire  prompts  to  the  sexual  act ;  but  consciousness  of  inqiotence.  and 
the  impossibilit}'  of  gaining  the  consent  of  an  adult  to  sexual  approach, 


544  J   SYSTE2I  OF  LEGAL  MEBICIXE. 

cause  siicli  old  men  to  seek  cMldi-eu,  in  wliose  igTiorance  ther  would 
conceal  theii-  deiieieney.  In  such,  men  mental  failui-e  is  an  invariable 
accompaniment  of  such  acts.  Sexual  perversion  (erotic  feticMsm)  might 
lead  to  an  unnatiu'al  preference  for  childi*en.  Finally,  in  a  certain  pro- 
portion of  cases,  children  fall  victims  to  the  sexual  appetite  of  males 
through  the  accidental  coincidence  of  association,  inordinate  passion  in 
the  male,  and  favoring  cii'cumstances. 

In  cases  of  alleged  rape  of  childi'en,  consideration  of  the  physical 
condition  of  the  genitals  of  both  parties  becomes  very  important.  The 
younger  and  more  undeveloped  the  child,  the  smaller  the  possibility  of 
actual  penetration  by  the  adidt  male  organ.  As  a  rule,  owing  to  the 
common  disproportion  of  size,  the  sexual  contact  is  confined  to  the  w\l- 
var  fissiu'e.  Where  this  disproportion  exists,  and  the  forced  entrance  of 
the  penis  is  attempted,  laceration  of  the  child's  genitals  is  almost  inevi- 
table, owing  to  the  delicacy  of  the  infantile  tissues.  Still,  where  lacera- 
tions of  a  child's  genitals  are  found,  the  question  arises  at  once  whether 
they  could  have  been  caused  by  the  erected  male  organ.  Owing  to  the 
limited  power  of  the  penis  to  overcome  resistance,  where  serious  or  exten- 
sive lacerations  of  a  child's  genitals  are  found  they  are  to  be  attributed 
to  brutal  attempts  to  bring  about  dilatation  by  the  fingers  or  other  un- 
yielding object.  It  should  be  remembered  tliat  even  a  child's  genital 
passage  may  be  enormously  dilated  by  j)ersistent  gentle  efforts,  without 
the  production  of  lesions ;  and  marked  disiDroportion  between  the  age 
and  the  size  of  the  genital  passage  of  a  child  should  be  given  weight  as 
e^ddence  that  she  has  been  used  for  sexual  piu-poses.  * 

Secondary  Consequences. — ^Medico-legal  questions  may  arise  con- 
cerning the  ultimate  consequences  of  rape  to  the  ^-ietim.  Impregnation 
may  result,  and  place  additional  Hability  on  the  radish er.  Injuries  inflicted 
by  the  rape  may,  aside  from  the  effects  of  venereal  infection,  seriously 
affect  the  health  of  the  female  ;  and  such  injmies  may  even  cause  death, 
as  nimierous  cases  reported  l)y  Tardieu,  Taylor,  Casj^er,  and  others  attest. 
Such  eases  show  that  death,  iinder  such  cii'cumstances,  may  result  earl}^  or 
late,  in  accordance  with  the  immediate  cause.  Thus  it  may  be  due  to 
shock,  hemorrhage,  sepsis  through  wounds  inflicted  in  the  immediate 
sexual  act,  and  to  hemorrhages  into  the  central  nervous  system.  Geni- 
tal wounds  may  dbectly  or  indirectly  implicate  the  peritoneal  cdiYxtY  and 
lead  to  a  fatal  peritonitis.  Since  sepsis  may  play  a  veiy  important  part 
in  these  cases,  it  becomes  of  the  gi-eatest  importance  that  the  physician 
examining  such  an  injui'ed  female  exclude  by  the  most  rigid  asepsis  in 
his  examination  the  possibility  of  a  defense  based  on  the  assumption 
that  he  made  secondaiy  sepsis  possible  by  his  manipulations  and  in- 
struments. 

Rape  of  Male  Children. — The  Enghsh  common  law  does  not  recog- 
nize rape  of  male  childi-en  by  mature  females,  but  such  an  offense  is 
recognized  by  the  law  of  some  Continental  nations.  In  the  United  States 
such  crimes  are  punishable  under  the  laws  of  some  States,  as  indecent 
assaidt.  The  most  serious  consequences  to  such  children  is  venereal  dis- 
ease, aside  from  moral  injury,  and  cases  of  this  kind  are  not  of  gi-eat 
rarity. 

*  Cf.  Indecent  Assault  upon  Children,  vol.  i.,  p.  649. 


SEXUAL   CRIMES.  545 


SEXUAL  ABUSE   OF   CHILDREN  * 

Closely  related  to  the  crime  of  rape,  but  widely  separated  from  it  in 
a  legal  sense,  is  sexual  abuse  of  children.  The  common  law  docs  not 
recognize  sexual  abuse  of  tins  nature  as  su(^h,  but  such  inujionil  acts 
may  Ix'come  the  basis  of  legfd  proceedings,  and  various  medi(.'o-lcg-al 
questions  may  be  raised  in  siuih  cases. 

Sexual  al)nse,  in  the  sense  in  which  it  is  here  employed,  signifies  sex- 
ual manipulations  which  are  unrelated  to  the  normal  sexual  act.  Mun- 
nstupration  nuiy  l)e  pra(;ticed  upon  the  person  of  a  male  or  female  child 
by  a  man  or  woman ;  or  children  may  be  induced  to  perform  such  an 
act  on  one  another  as  an  exhiljition ;  or,  again,  they  may  be  persuaded 
to  manipulate  the  genitals  of  the  seducer,  male  or  female. 

For  the  most  part,  the  cases  of  this  kind  that  have  the  greatest 
medico-legal  imj)ortan(;e  are  those  in  which  female  children  are  abused 
by  men.  In  such  cases,  questions  arise  similar  to  those  that  are  of  such 
importance  in  instances  of  rape  under  like  circumstances.  The  age  of 
the  alleged  victim  would  be  determinate.  It  would  be  essential  to  con- 
sider any  evidences  the  female  genitals  might  afford  of  the  natm'c  of 
abuse.  The  presence  of  coarse  anatomical  changes  will  depend,  of 
course,  upon  the  force  or  brutality  of  the  manipulations  to  which  the 
parts  have  been  subjected,  and  as  well  upon  the  frequency  \\\\\\  which 
they  have  been  repeated.  Merely  gentle  titillation  woidd  leave  no  sign 
behind,  unless  frequently  repeated ;  and  it  would  be  necessary  to  em- 
phasize the  impossibility  of  distinguishing  a  condition  of  irritation 
induced  at  the  hands  of  a  second  person  from  that  due  to  self-abuse. 
At  the  same  time,  the  child  is  apt  to  confi.ne  her  manipulations  to  the 
vestibule ;  a  second  person  of  maturer  years  would  be  almost  cei-tain  to 
attempt  to  enter  the  vagina.  The  state  of  the  h^anen  and  the  hymeneal 
opening,  as  well  as  the  capacity  of  the  vagina,  might  give  evidence  of 
laceration  or  dilatation.  Wliere  gross  anatomical  changes  of  the  geni- 
tals of  a  female  child  are  found,  the  question  of  rape  arises ;  but  it  must 
l)e  remembered  that  such  changes  are  much  more  commonly  the  result  of 
manipulations  made  preparatory  to  an  attempt  to  introduce  the  penis  than 
the  result  of  the  primary  introduction  of  that  organ.  Too,  injuries  may 
be  found  which  could  not  possibly  have  been  induced  by  the  male  organ. 

Other  forms  of  sexual  abuse  of  cliildi-eu  can  seldom  afford  physical 
evidence  of  their  practice  in  effects  left  in  the  genitals.  Medico-legal 
questions  in  relation  to  such  crimes  will  oftenest  arise  in  respect  to  the 
mental  condition  of  the  perpetrators. 

SODOMY. 

In  English  common  law,  sodomy  is  a  very  broad  term,  covering  ped- 
erasty, buggery,  and  bestiality.  The  common  law  defines  sodomy  as 
carnal  knowledge  committed  against  the  common  order  of  nature  by 
man  with  man,  or  with  wonuiu  ;  or  by  man  or  woman  with  a  beast.  In 
early  times  in  England  the  offense  was  regarded  as  highly  penal.  Grad- 
ually it  came  to  be  looked  upon  as  less  heinous,  until  by  statute  it  was 

*  Loc.  cit. 


546  ^   SYSTEM  OF  LEGAL  MEDICINE. 

again  declared  to  be  a  felony  in  the  reign  of  Henry  VIII.  This  statute 
was  repealed  and  again  re^dved  in  the  time  of  EHzabeth.  Thus,  by  the 
common  law  of  the  States  sodomy  is  an  offense ;  but  whether  it  is  a 
<3rime  or  a  misdemeanor  is  uncertain.  In  England  it  was  formerh^  the 
custom  to  bmm  or  bury  the  offender  alive.  In  the  reign  of  Richard  I.  it 
was  customary-  to  hang  a  man  and  drown  a  woman  proved  guilty  of  the 
crime.  The  piuiishment  now  in  England  is  penal  ser\dtude  for  ten 
years  or  more. 

With  sodomy,  as  with  raj)e,  it  is  necessary  to  have  23roof  of  penetra- 
tion in  order  to  establish  the  fact  of  carnal  intercom'se.  The  e^ddence 
of  a  prosecuting  witness,  if  an  accomplice,  is  not  alone  sufficient.  The 
English  common  law  takes  no  cognizance  of  the  common  form  in  which 
coitus  is  imitated  by  males  between  the  thighs — coitus  inter  femora  ;  and 
it  makes  no  reference  to  an  unnatural  sexual  act  that  women  indulge  in — 
namely,  Lesbian  love,  or  tribadism. 

Pederasty  in  law  is  the  act  of  immissio  penis  in  anum.  Both  parties  to 
the  act,  where  both  are  voluntary  participants,  and  both  have  reached 
the  age  or  condition  of  legal  responsibility,  are  j^unishable.  As  indicated 
"by  the  legal  understanding  of  the  term,  pederasty  may  be  accompUshed 
by  male  with  male  or  female. 

Pederasty  is  both  active  and  passive.  The  active  part  is  always 
taken  by  a  male ;  the  passive  role  may  be  enacted  by  a  male  or  female. 
The  active  party  may  perform  the  act  upon  the  person  of  the  passive 
party  by  force  and  without  the  consent  of  the  latter ;  and  under  such 
cii'cumstances  pederasty  becomes  similar  to  rape.  On  the  other  hand, 
the  act  may  be  permitted  by  the  passive  party,  who  may  be  legally  in- 
capable of  consent.  Again,  a  passive  party  may  persuade  a  legally 
irresponsible  active  party  to  the  crime.  However,  the  majorit}"  of  the 
instances  of  the  crime  are  cases  where  there  has  been  mutual  consent  of 
both  parties,  with  mutual  responsibility,  and  consent  of  the  passive  party, 
with  legal  irresponsibility.  Forcible  performance  of  the  act  by  the 
active  party  withoiit  the  consent  and  against  the  will  of  the  passive 
party  is  rare. 

As  in  rape,  so  in  pederasty,  owing  to  the  paramount  importance  of 
physical  evidence,  there  has  been  a  persistent  effort  made  to  discover 
pathognomonic  physical  signs  left  after  performance  of  the  act.  Many 
such  signs  have  been  described  by  various  observers,  but  they  are  of  no 
trustworthy  diagnostic  value.  Thej^  call  for  notice  here,  if  for  no  other 
reason  than  to  have  then*  worthlessness  pointed  out.  It  is  clear  that  the 
person  of  the  active  pederast  could  offer  no  unequivocal  evidence  that 
he  had  performed  pederasty.  Tardieu  thought,  however,  that  habitual 
indulgence  in  the  act  led  to  a  change  in  the  form  of  the  glans  penis,  at 
least  in  some  instances.  In  some  pederasts  he  found  the  organ  pointed. 
Such  a  peculiarity  of  form,  however,  could  be  justty  attrilrated  only  to 
a  develoiDmental  defect.  The  same  may  be  said  of  constriction  of  the 
body  of  the  penis  at  some  distance  behind  the  glans,  which  might  be  pre- 
sumed to  be  due  to  pressure  by  the  contracted  sphincter  ani  of  the  pas- 
sive part}'  to  the  act.  Abrasions  of  the  penis  might  result  from  its 
forcible  introduction  into  the  anus,  but  such  signs  could,  of  course,  have 
no  diagnostic  value. 

Passive  pederasty  would  seem  capable  of  inducing  more  determinate 
anatomical  changes  in  the  person  given  to  it ;  but  practically  such  pos- 


iSKXLAL    CniMES.  547 

sil)le  alterjitions  are  of  little  ijositive  value  save  in  a  few  instances. 
AYliere  the  iiiniiissio  penis  in  anntn  lias  been  forced,  espeeially  in  children, 
abrasions,  lacerations  of  the  mucous  menil^rane,  and  even  more  extensive 
tears,  with  accompanying-  signs  of  intiamniation,  niigiit  result;  but  in 
such  cases,  even  moi-e  than  in  cases  of  rape,  there  woidd  be  the  presump- 
tion that  such  wounds  were  caused  by  a  more  unyielding  obj<^ct  than  the 
penis.  In  adults  the  spliincter  ani  is  more  readily  capable  of  dilatation 
than  in  cluldren ;  and  for  this  reason,  where  an  adult  permitted  the  a(,'t 
of  pederasty,  tliere  might  be  no  evidence  of  it  found  in  the  subsequent 
i'oudition  of  the  tissues  al)out  the  anus.  There  are  certain  c<jnditions  of 
the  anus  and  surrounding  parts  that  have  been  considered  diagnostic  of 
habitual  passive  pederasty  since  the  time  of  the  Romans.  Considera- 
tion of  these  signs  will  show,  however,  that  they  are  not  of  unequivocal 
significance.  Relaxation  of  the  tissues  about  the  anus,  with  conical 
deepening  of  the  normal  anal  depression ;  dilatation  of  the  anal  orifice ; 
relaxation  of  the  sphincter  ani ;  obliteration  of  the  creases  of  the  mu- 
<^ous  membrane  and  skin  which  usually  radiate  from  the  anus ;  and 
hypertrophic  growths  of  the  mucous  membrane,  ai-e  some  of  the  signs 
of  passive  pederasty  enumerated  by  observers.  Their  slight  independent 
importance  as  signs  of  pederasty  is  at  once  appflrent ;  and  the  same  is 
true  of  the  various  forms  of  proctitis  that  might  be  caused  by  the  vice. 

Demonstration  of  the  presence  of  spermatozoa  in  the  person  of  the 
passive  party  might  atford  valuable  evidence.  Should  they  be  found  in 
the  rectum,  the  proof  would  be  conclusive;  found  elsewhere  about  the 
person,  they  would  be  of  no  value  as  evidence,  save  in  eases  where  the 
male  indi\dduals  concerned  were  demonstrably  below  the  age  of  piibertv. 
Venereal  diseases  might  be  communicated  by  pederasty.  Where  such 
disease  is  seated  in  the  rectum  and  about  the  anus  exclusively,  it  is  of 
some  value  as  indicating  the  vice ;  but  it  is  to  be  remembered  that  such 
parts  may  become  the  seats  of  venereal  diseases  communicated  in  other 
ways  than  by  means  of  pederasty. 

Bestiality  cannot  well  afford  anatomical  evidences  of  its  practice  as 
far  as  the  male  or  female  ciiminal  is  concerned ;  but  under  favoraT)le 
circumstances,  the  animals  made  use  of  by  males  may  present  signs 
about  the  genitals  of  the  treatment  to  which  they  have  been  subjected^ 
and  humau  spermatozoa  might  be  demonstrated  in  the  genital  passages 
or  in  the  dried  accretions  about  the  genitals  of  the  aiiimal. 

Tribadism,  iDiniissio  clitoridis  in  vaginam,  likewise  leaves  no  distinctive 
•evidence  behind.  Though  such  a  ^-ice,  long  practiced,  would  ultimately 
lead  to  more  or  less  change  about  the  female  genitals,  these  alterations 
would  not  necessarily  be  different  from  those  that  follow  repeated  man- 
ual irritation.  In  females  given  to  the  practice  of  tribadism  an  enlarged 
clitoris  is  usually  fouiul ;  but  enlargement  of  the  clitoi-is  in  itself  could 
indicate  nothing  with  I'egard  to  such  an  unnatural  ^'iee.  Its  medico- 
legal importance  is  slight. 

The  psychical  aspect  of  pederasty  and  other  unnatui*al  sexual  acts  is 
•considered  under  Sexual  Perversion. 

INCEST. 

Incest  is  the  carnal  copulation  of  a  man  and  a  woman  related  to  each 
•other  in  any  of  the  degrees  •^\'ithin  which  marriage  is  prohibited  by  law. 


548  ^   SYSTEM  OF  LEGAL  MEDLCINE. 

This  offense  is  unknown  to  the  common  law,  and  is  merely  a  statutoiy 
crime.     By  most  of  the  States  it  is  ]Dnnished  as  felony. 

In  some  cases  of  incest,  questions  might  arise  for  solution  not  unlike 
those  met  in  eases  of  rape  of  childi-en,  where  the  sexual  act  might  be 
performed  under  such  circumstances  as  to  constitute  at  once  the  crimes- 
of  incest  and  rape. 

The  crime  of  incest,  in  its  most  aggravated  forms,  as  between  parent 
and  child  or  brother  and  sister,  is  so  rej^ugnant  to  the  moral  sense  that 
it  is  difficult  to  conceive  it  as  occurring  save  as  an  expression  of  a 
psychopathological  state;  and  in  many  recorded  instances  of  incest 
it  has  been  possible  to  establish  the  influence  of  such  a  factor  in  its- 
causation. 

In  relation  to  the  possible  role  of  an  anomalous  psj' chical  state  in  the 
causation  of  this  repugnant  crime,  it  is  of  interest  to  note  the  soui'ce  of 
the  universal  aversion  there  is  among  mankind  to  the  marriage  of  blood 
relations.  Von  Krafft-Ebing*  says  that  ''  the  preservation  of  the  moral 
l^urity  of  family  life  is  one  of  the  fruits  of  development  in  culture  [cul- 
tur-enfn-ic'klnn(j)y  He  regards  it  as  a  product  of  evolutional  development. 
In  the  sense  in  which  this  is  meant,  it  does  not  account  for  the  fact.  Eth- 
nologists have  advanced  many  ingenious  theories  to  account  for  tMs 
feeling  of  aversion  to  sexual  relations  with  near  kindred,  wMcli  is  weU- 
nigh  universal  among  mankind,  savage  as  well  as  ci^dlized ;  but  aU  these 
explanations  resolve  themselves  into  the  statement  that  incest  is  avoided 
as  -A  result  of  teaching.  When  a  phenomenon  like  tliis  is  practically  of 
universal  manifestation,  its  occurrence  must  depend  upon  something- 
more  fixed  and  unalterable  than  accidental  instruction,  or  a  general  I'ec- 
ognition  of  the  evil  effects  of  consanguineous  marriages ;  it  must  arise 
from  some  inherent  psychophysiological  peculiarity  common  to  the  race. 

This  inlierent  aversion  to  marriage  with  a  relation,  it  may  be  said,  is 
an  instinct,  but  this  does  not  explain  the  matter.  The  origin  of  the  in- 
stinct must  stiU  be  explained.  There  is  no  inherent  repugnance  to  mar- 
riage with  a  relation  dependent  upon  the  mere  fact  of  consanguinity ; 
the  aversion  exists  to  sexual  union  of  males  and  females  that  have  lived 
in  the  closest  and  most  intimate  association  from  early  childhood.  This 
aversion  has  been  natm-ally  extended  by  analogy  to  include  repugnance 
to  marriage  between  persons  of  the  same  blood.  What  we  have"  to  ac- 
count for,  then,  is  not  aversion  to  marriage  of  relations  jjer  se,  but  the 
repugnance  to  mutual  sexual  congress  there  is  in  those  that  have  devel- 
oped in  intimate  association. 

The  origin  of  this  instinctive  aversion  to  incest  is  to  be  found  in  a 
study  of  the  psychology  of  sexual  development.  NormaUy,  in  human 
beings,  sexuality  is  acquired  late;  the  child  passes  through  a  long  period 
of  development  before  the  distinctive  sexual  characteristics  make  their 
appearance.  During  the  primary  period  of  asexual  life  the  most  inti- 
mate and  definite  mental  associations  are  formed,  and  these  are  related 
to  those  persons  with  whom  the  child  is  in  constant  social  (family)  con- 
tact. In  the  nature  of  normal  circumstances,  the  child  nmst  first  acquu'e 
a  fixed  asexual  relationship  to  those  in  the  intimate  society  of  whom  it 
develops.  With  the  oncoming  of  puberty,  emotional  longings  of  a  new 
and  unknown  character  are  experienced  by  the  individual  which  are 

*  Psi/chojxithia  Sexitalis,  p!  431. 


SF.XIAL    CRIMES.  54'J 

diivcti'd  iionnally  toward  persons  of  the  opposite  sex;  tliis,  we  believe^ 
l;M-,i;i'ly,  if  not  exclusively,  by  reason  of  sii<:g-estion  and  example  made 
operative  before  sexuality  has  asserted  itself.  But  those  of  the  opjjosite 
sex  in  the  same  family  (mother,  sisters),  standin<^'  as  tlicy  do  iii  the 
precedent  fixed  mental  relation  to  the  developing'  youth,  and  beinj;  sub- 
jectively in  a  mental  attitude  identical  with  his  own,  ai"e  the  last  persons- 
toward  whom  these  new  emotions  can  be  directed.  Those  of  the  oppo- 
site sex  that  have  been  reared  with  the  maturinj^  individual  have  so  long- 
occupied  an  asexual  |)la(!e  in  his  thought  that  they  naturally  fail  to  enter 
into  association  witii  the  new  experience.  The  new  h)ngings — incom- 
prehensible and  indefinite  at  first — liecome  by  veiy  necessity  directed 
toward  persons  who,  l)y  virtue  of  their  being  comparative  or  absolute 
strangers,  are  the  more  readily  brought  into  a  causal  relationship  with 
the  strange  emotions.  Or,  to  state  the  matter  in  a  different  way,  the- 
sexual  feelings,  under  normal  cu'cumstances,  are  directed  toward  com- 
parative strangers  because  intimate  associates  (in  the  family)  through 
infanc}''  and  childhood  have  filled  up  the  measure  of  the  individual's' 
mental  associations  possible  in  relation  to  them.  Under  normal  circum- 
stances, then,  new  and  strange  sexual  feelings,  when  arising  spontane- 
ously, are  directed,  according  to  an  evident  psychophysiological  law,, 
toward  those  persons  that  have  not  impressed  the  developing  child  in  the 
ways  necessarily  att(mdant  ui)on  prolonged  primary  intima(;y.  Though 
oftentimes  arising  spontaneously,  the  primary  sexual  emotions  are  ordi- 
narily excited  into  activity  through  the  influence  of  external  impressions. 
Association  with  the  members  of  a  family,  however,  is  attended  by  the 
ultinuite  development  of  certain  fixed  forms  of  intellectual  and  emotional 
reaction  in  the  child ;  so  that  persons  who,  by  association  with  an  indi- 
vidual tin-ough  the  asexual  period  of  development,  had  come  to  exert 
certain  fixed  influences,  woidd  be  the  less  capable  of  exciting  new  emo- 
tions ;  impressions  made  by  them  would  excite  the  accustomed  paths  of 
neuropsychical  association  ;  and  when  that  period  of  life  in  which  sexual 
stimuli  become  effectual  had  been  reached,  they  would  necessarily  be 
derived  from  an  individual  who  had  stood  in  no  intimate  and  fixed  rela- 
tion to  the  child.  The  manner  of  the  fii-st  sexual  stimulation  is  largely 
determinate  for  the  future  direction  of  sexual  desire.  Once  projected 
outside  tlie  family  circle,  it  is  never  changed  save  in  obedience  to  anoma- 
lous circumstances. 

As  sexuality  develops,  it  ccmies  to  exercise  the  most  powerfid  influ- 
ences over  the  individual,  finally  leading  to  the  severance  of  the  associa- 
tions of  childhood  through  the  estal)lislnnent  of  sexual  relations  with 
the  person  who  has  excited  sexual  feeling  of  sufficient  intensity  to  over- 
come primary  ties  of  intimacy.  As  a  result  of  peculiar  or  anomalous 
circumstances,  like  those  of  comparative  isolation  of  a  faniily,  incestuous 
relations  would  almost  certainly  arise ;  or  too  early  and  too  intense 
development  of  the  sexual  instinct  might  preclude  the  development,  or 
acquisition,  of  the  normal  (or  usual)  psj^chophysiological  aversion,  and 
lead  to  incestuous  instinct  and  practice;  again,  the  aversion  i)rimarily 
ac(piired  might  be  lost  as  a  result  of  mental  disease,  or  temporarily 
su})presse.d  by  the  dominance  of  pathological  hyperexcitation  of  sexual 
desire. 

It  might  l)e  urged  that  to  prove  the  validity  of  this  explanation  of 
the  uni^•ersal  prevalence  of  human  aversion  to  incestuous  relations,  it 


550  -i   SYSTEM   OF  LEGAL  MEDICINE. 

■would  l3e  necessaiy  to  show  the  operation  of  siicli  a  tendency  in  the 
lower  orders  of  animals.  AVe  should  expect  to  find  such  a  psvchosexual 
law  operative  only  in  lower  animals  having  a  long  period  of  asexual  de- 
veloijineut  and  presenting  a  gi-eat  variety  of  psychosocial  associations 
other  than  those  of  a  true  sexual  character.  Such  a  law  could  lie  opera- 
tive only  in  animals  manifesting  the  beginnings,  at  least,  of  the  more 
comphcated  psychosocial  relations. 

These  considerations  place  the  normal  aversion  to  incest  uj)on  a 
psychophysiological  basis,  and  emphasize  the  need  there  is  to  investigate 
the  mental  condition  of  the  criminal  in  all  aggravated  cases  of  this 
crime. 

EXHIBITIOX — INDECEXT   EXPOSUKE. 

Indecent  exposure  is  such  intentional  exhibition,  in  a  public  place,  of 
the  naked  human  body,  or  such  exposure  of  the  private  members,  as  is 
calculated  to  shock  the  feelings  of  chastity  or  corrupt  the  morals  of  those 
who  witness  it.  This  offense  must  be  committed  in  a  public  place  and  in 
the  sight  of  more  tlian  one  person  in  order  to  be  punishable  under  the 
common  law.  However,  the  statutory  provisions  of  various  States  are 
broader.  The  chief  medico-legal  interest  that  attaches  to  this  minor  sex- 
ual crime  is  in  regard  to  the  mental  condition  of  the  perpetrators  of  it. 
There  is  nothing  in  the  crime  that  precludes  the  possibihty  of  its  being- 
committed  by  normal  individuals,  but  under  all  circumstances  the  act  of 
genital  exposui-e  is  in  itself  so  obviously  silly  and  pm-poseless  that  it 
cannot  fail  to  give  rise  to  the  presmnption  of  the  influence  of  anomalous 
mental  factors  in  its  causation.  The  records  of  cases  that  have  come  to 
ti'ial  bear  out  this  view.  Indeed  it  is  seldom  that  the  crime  is  not  the 
result  of  congenital  mental  deficiency  or  acquired  insanity;  and  this 
fact  should  be  clearly  understood  and  given  weight  in  trials  for  such  a 
crime. 

SEXUAX,   PERVERSION. 

The  sexual  crimes  have  been  considered  chiefly  with  respect  to  the 
evidence  that  might  be  invoked  to  establish  the  fact  of  the  perpetration  of 
them ;  here  the  pui-pose  is  to  examine  a  psychical  factor  which  frequently 
becomes  the  cause  of  various  criminal  sexual  acts — namely,  sexual  per- 
version. 

To  Westphal,*  Tarnowsky,f  von  Ki'afft-Ebing,|  and  MoU  §  we  are  in- 
debted for  a  systematic  study  of  the  psychosexual  anomalies ;  but  von 
Krafft-Ebing  has  done  by  far  the  most  toward  elucidating  them.  Here 
nothing  more  than  a  resume  of  ih.Q  estabhshed  facts  and  prevalent  theories 
can  be  attempted. 

All  manifestations  of  the  sexual  instinct  that' are  uot  in  accord,  directly 
or  indirectly,  \v-ith  the  physiological  provisions  of  nature  for  the  proiiaga- 
tion  of  the  race  may  justly  be  regarded  as  anomalo^^s,  as  perversions ;  but 

*  Archw  f.  Psjjchiatrie,  vol.  i.,  p.  651. 

t  Die  kraukhaften  Erscheinuiujen  des  Ge.tchlechtssinne.v,  Berlin,  1886. 

+  Psychopathia  Sexualis,  Philadelphia,  1892. 

6  Contrdre  Sexualempfinduug. 


.SKXiJL  cniMEi^.  551 

it  becomes  of  the  greatest  importance  to  determine  in  how  far  such  phe- 
nomena are  due  to  disease,  or  to  what  extent  tliey  are  tlie  result  of  vice. 
For  a  correct  comprehension  of  the  various  deviations  to  which  tlie 
sexual  instinct  is  subject  a  thorough  kiujwledge  of  the  normal  sexual 
manifestations  is  nccc^ssary. 

Psychosexual  Development. — Owing  to  the  fact  that  the  niajoi-ity  of 
males  feel  sexually  attracted  by  females,  and  rice  irrsd,  it  is  eoneludetl  tliat 
the  expression  of  this  desire  is  the  normal  manifestation  :  nuu'e  than  this, 
it  is  assumed  that  this  desire  of  each  sex  for  the  other  is  inherent  and  con- 
ditioned by  the  anatomical  peculiarities  which  determine  sex ;  that  when 
an  individual  is  given  distinctive  sexual  organs  there  are  simultaneously 
im})lanted  the  germs  of  cori'esponding  psychosexual  characteristics  which 
subsequently,  in  spite  of  any  external  influence,  will  distinguish  the  in- 
dividual as  a  sexual  being.  Following-  this  method  of  reasoning,  in  cases 
which  present  a  deviation  from  this  normal  relation  of  anatomical  and 
psychical  endowment  the  peculiar  phenomenon  is  explained  ]jy  the  as- 
sumption that  the  want  of  correspondence  is  due  to  the  congenital  im- 
plantation of  an  inappropriate  sexual  instinct;  or  the  want  of  normal 
correspondence  between  instinct  and  sex  is  regarded  as  due  to  external 
influences  that  have  disturbed  the  once  normal  relation — that  is,  the  sexual 
perversion  is  an  acquired  characteristic.  Thus  there  are  theoretically  two 
■categories  of  sexual  perversion — the  congenital  and  the  aajuired.  It  is  still 
an  open  question  whether  we  are  justified  in  making  a  hard-and-fast  line 
of  demarkation  between  these  psychosexual  anomalies ;  certain  it  is  that 
with  our  present  means  of  diiferential  diagnosis  we  are  often  left  in  doubt 
as  to  whether  a  given  case  is  to  be  placed  in  one  or  the  other  of  these 
categories.  The  many  sources  of  error  iuherent  in  the  diagiujsis  of  such 
anomalies  are  due  in  the  main  to  the  subjective  nature  of  the  data  upon 
which  the  physician  must  depend  for  information  and  idtimate  judgment. 

Anatomical  differentiation  of  the  sexes  preceded  the  development  of  the 
complementary  sexual  instincts  characteristic  of  the  two  sexes.  Sexual 
desire,  whether  ultimately  arising  from  the  primitive  sense  of  hunger  or 
not,  sprang  directly  from  pleasurable  sensation  experienced  under  cir- 
cumstances of  peculiar  contact  of  two  organisms.  Such  contact  could 
be  essentially  peculiar  only  after  the  development  of  organs  possessed  of 
peculiar  sensibility.  With  the  attainment  of  this  stage  of  evolutional  de- 
velopment the  contact  (conjugation)  of  organisms  of  complementaiy  sex 
is  the  only  contact  that  could  be  influential  in  the  further  develo})nient 
and  differentiation  of  the  sexes ;  for  the  conjugation  of  organisms  of  like 
sex  could  but  have  been  devoid  of  results  beyond  the  immediate  influence 
exerted  by  it  upon  the  organisms  concerned.  With  the  limitation  of 
fruitfulness  to  the  conjugation  of  organisms  mutually  complfuientary 
arose  the  conditions  for  a  more  distinct  differentiation  of  sexual  organs, 
and  the  acquisition  of  the  psychical  supplements  of  sexual  differentiation  ; 
that  is,  the  intuitive  recognition  of  sex,  which  com])rises  self-recognition 
sexually  and  its  complement,  and  the  intuitive  impulse  to  a  definite  form 
of  action  and  sensory  stinndation.  The  anatomical  and  functional  ditt'er- 
ences  which  accompanied  sexual  differentiation  were  determinate  in  sup- 
plying the  conditions  necessary  for  the  origin  and  development  of  dis- 
tinctive psychosexual  characteristics,  which  in  their  turn  served  to  render 
sexual  differences  in  general  more  marked.  Thus  the  conditions  that 
must  have  attended  the  gradual  evolution  of  the  sexes  anatomically,  and 


552  ^   SYSTEM  OF  LEGAL   MEDICIXE. 

tte  gi-adual  acquisition  of  a  sexual  instinct  appropriate  to  each  sex,  were- 
sncli  that  tliough  the  instinct  mnst  have  reached  full  develoi3ment  second- 
ardv  to  the  evolvement  of  complementary  generative  organs,  the  fuH}^  de- 
veloped desire  for  the  opposite  sex  was  but  remotely  connected  with  the 
sexual  organs  per  se.  In  its  primitive  natiu^e  the  sexual  instinct  or  desire 
must  have  been  an  impulse  to  a  stimidus  arising  from  the  mechanical 
iiTitation  of  contact  of  the  sexual  organs  with  which  the  organism  was 
endowed.  The  fact  that  only  those  organisms  that  had  found  contact 
with  their  sexual  complements  would  be  instrumental  in  propagation  must 
necessarily  have  ultimately  evolved  the  secondary  psychosexual  character- 
istics of  sexual  instinct ;  that  is,  sexual  desire  for  the  opposite  sex.  The 
fully  developed  sexual  desire  for  the  opposite  sex  is  thus  exclusivel}^  a 
secondaiy  evolution  from  the  primitive  sexual  impulse  to  mere  contact. 
Kecessardy  comparatively  a  longer  period  of  evolutional  development 
woiild  be  requii-ed  for  its  perfection  than  for  the  development  of  that  part 
of  the  instinct  directly  connected  with  the  sexual  organs.  O'^dng  to  the 
nature  of  this  desu-e  for  union  with  the  opposite  sex — its  independent 
character — when  evolved  to  its  highest  development  it  is  purely  psychical, 
and  therefore  quite  independent  of  the  sexual  organs  pter  se.  Once  de- 
veloped to  this  degree  of  comparative  independence  the  sexual  instinct  be- 
comes capable  of  hereditar}^  transmission  quite  independently  of  the  an- 
atomical nature  of  the  sexual  organs  of  the  inheriting  organism.  In  higher 
organisms,  where  psychical  character  is  transmitted  independently  of 
physical  iDccuiiarities,  we  thus  find  that  there  may  be  lack  of  harmony 
between  the  fundamental  and  the  secondary  or  psychical  elements  of  the 
sexual  instinct.  Commonly  the  fundamental  elements  of  sexual  desire, 
including  esj^ecially  the  impidse  to  stimulation  of  the  sexual  organs,  are 
infinitely  more  powerful  than  the  secondary  psychical  elements,  because 
they  are  dependent  upon  lower  nervous  centers,  and  they  are  manifested 
much  earlier  in  the  life  of  the  organism.  An  inherited  psychical  instinct 
for  union  with  the  opposite  sex  cannot  attain  exj)ression  until  develoi^- 
nient  has  taken  place  to  a  degi'ee  that  permits  recognition  of  sexual  differ- 
ence; it  is  therefore  of  secondary  and  subsequent  development  with  re- 
spect to  the  fundamental  elements  of  sexual  desire. 

Anomahes  of  the  fundamental  element  of  sexual  desire  (impulse  to 
genital  stimulation)  occur  only  where  there  are  also  marked  anomalies- 
of  physical  (peripheral)  and  nervous  organization ;  but  the  secondary 
elements  (psj'chical),  owing  to  theii'  dependence  upon  the  higher  nervous- 
organization  (cerebral  cortex),  are,  in  a  sense,  less  definite  in  character. 
Pui'ely  jDsychical  characteristics  in  higher  animals,  and  especially  in  man, 
are  commonly  less  truly  and  perfectly  reproduced  in  offsj^ring  by  inheiit- 
ance  than  are  the  more  definite  organic  characteristics ;  and  by  reason  of 
this  imperfection  or  variation  of  psychical  inheritance,  education  becomes 
of  prime  importance  in  determining  the  psj^chical  characteristics  which 
distinguish  the  mature  indi-^-idual.  In  the  nature  of  things,  since  the 
liiglier  psychical  characteristics  are  of  gradual  development  in  the  lifetime 
of  the  indindual  organism,  they  are  the  more  subject  to  favorable  or  un- 
favorable influence  from  without,  and  thus  such  inherited  potentialities 
might  be  emphasized,  altered,  or  obscured. 

Such  considerations  as  these  should  lead  us  to  expect  the  fundamental 
element  of  sexual  desire  to  be  a  fairly  constant  quantity  in  inheritance  in 
the  physically  normal  man ;  on  the  other  hand,  we  should  expect  more 


SEXUAL    CRIMES.  553 

variation  in  the  socoiidaiy  or  psychical  eleiiieiit.  Relatively  indcpeiidciit 
of  the  sexual  or<;aiis  as  we  have  seen  this  secondary  element  to  Ije,  we  can 
conceive  that  it  ini<i,ht  be  well  developed  in  an  individual  whose  g-enitals 
were  so  markedly  defective  as  to  be  incapable  of  normal  functions.  The 
rule  is,  of  course,  the  transmission  of  distinctive  sexual  <n'g;ans,  with  the 
virtual  transmission  of  an  appropriate  sexual  instin(;t;  but  rememljei-injj^ 
the  inde))eudenee  of  the  psychical  element  of  sexual  appetite,  and  always 
the  possibilities  of  iidieritance  from  the  mah;  and  female,  the()retically 
we  shouhl  expect,  also,  tlie  occasional  transmission  of  definite  sexual 
origans  tog'ether  with  an  inappropriate  or  opjxjsite  sexual  instinct.  In 
such  a  case  the  inappropriate  sexual  instinct  mig-ht  be  as  strong  as 
in  (iases  Avliere  it  and  genital  conformation  were  entirely  in  harmony. 
Between  these  two  possible  extremes  there  may  be  all  degrees  of  varia- 
tion in  the  perfection  of  the  transnutted  psychical  instinct.  In  the  extreme 
<'ase  of  either  kind  the  inherited  instinct  Avould  attain  its  predestined  ex- 
pression in  spite  of  all  opposing  intluence  exerted  from  without;  but  in 
the  cases  between  the  extremes  the  final  expression  of  the  sexual  impulse 
woidd  be  determined  more  or  less  ])y  external  circrimstances — in  other 
words,  influenced  by  education.  Thus,  if  the  inherited  instinct  for  the 
opposite  sex  were  weak,  it  might  be  strengthened  by  api)ropriate  educa- 
tion ;  on  the  other  hand,  it  might  be  perverted  by  circumstances  exerting 
an  opposite  influence.  And  the  same  would  be  true  of  cases  in  whi(;h  the 
sexual  organs  and  sexual  inclinations  wei-e  out  of  harmony.  The  incon- 
gruous or  inverted  sexual  impulse  might  l)e  so  strong  as  to  reach  its  pre- 
destined expression  in  spite  of  all  opposing  influences ;  or,  less  strongly 
imphiuted,  it  might  be  altered  in  direction  by  force  of  educating  influ- 
enct's. 

Such  considerations  but  lead  us  to  a  recognition  of  the  fact  that  the 
primary  or  fundamental  sexual  instinct  is  not  determinate  in  its  direction 
toward  sex ;  that  the  secondary  or  higher  psychical  element  is  the  deter- 
mining factor ;  and  that  since  the  latter  is  psychical,  it  is  sul)ject  to  wider 
variati(^)us  within  ordinarily  normal  limits  than  the  former.  Tlie  trans- 
mission of  the  higher  psychical  elements  of  sexual  instinct  must  V)e  sul>ject 
to  wider  variations,  also,  for  the  reason  that  the  inheritance  of  a  definite 
sexual  inclination  must  take  place  fi-om  one  of  two  parents  rather  than 
from  two  ;  for  the  necessary  conjunction  of  possible  inheritance  of  opposite 
sexual  inclinations  from  both  parents  would  necessarily  weaken  the  prob- 
al)ility  of  direct  inheritance  from  one  parent  of  a  definite  sexual  inclina- 
tit)n  for  one  or  the  other  sex.  We  know  that  anatomically  each  sex  has 
in  embryo  the  mor})hological  possibility  of  representing  the  ojjposite  sex; 
-and  likewise  each  individual  must  have  within  his  organization  the  i)ossi- 
bility  of  the  ultimate  develo])ment  of  the  two  secondary  (psychical)  in- 
stincts. Anatomically,  ordinarily  one  set  of  generative  organs  attains 
complete  devel()])ment,  with  dwarfing  of  the  complementary  set,  and  thus 
renders  the  sex  definite.  This  process  takes  place  as  a  result  of  hidden 
organic  causes,  though  these  causes  are  probably  intimately  connected 
with  the  process  of  nutrition.  With  the  psychical  side  of  sexuality  the 
case  is  somewhat  different.  As  has  been  shown,  there  are  many  ])ossible 
sources  of  variation  in  the  development  of  the  sexual  instinct;  and  more 
tlian  that,  actual  observation  has  disclosed  the  fact  that  in  the  Innnan 
race  the  development  of  the  psychical  pai't  of  sexuality  is  profoundly  in- 
fluenced by  a  definite  education,  which  is  usually  in  harmony  with  the 


554  ^   SYSTEM  OF  LEGAL  MEDICINE. 

anatomical  sex.  With  tlie  recognition  of  a  child's  sex  this  sexual  educa- 
tion begins,  and  under  normal  circumstances  it  is  always  in  harmony  with 
the  sex  represented  by  the  child.  Moreover,  that  the  educational  factor 
is  of  vast  importance  in  determining  an  abnormal  direction  of  sexual 
inclination  is  abundantly  shown  by  many  reported  cases. 

Allowing  the  importance  of  education  in  determining  the  charac- 
ter of  the  developed  sexual  instinct,  we  may  consider  the  manner  in  which 
its  influence  is  exerted.  A  long  period  of  the  life  of  the  human  being  is  nor- 
mally asexual.  During  this  asexual  period  the  developing  child  learns  the 
outward  distinguishing  marks  of  the  two  sexes ;  this  the  more  perfectly  the 
less  sexual  concealment  there  is.  Thus,  in  a  savage  state  the  human  being,, 
learning  at  once  the  sexual  (anatomical)  distinction  of  the  persons  around 
him,  and  recognizing  his  own  classification,  would  almost  inevitably  con- 
form to  the  manner  of  his  sex.  The  only  exception  to  this  is  where  cultiva- 
tion at  the  hands  of  others  brings  about  a  deviation.  And  the  comparative 
ease  with  which  such  a  deviation  can  be  brought  about  by  directed  effort  in 
early  years  but  emphasizes  the  fact  that  there  the  inheritance  is  usually  only 
of  the  primitive  sexual  instinct  (for  contact).  In  a  higher  state  of  civiliza- 
tion the  distinctions  between  the  sexes  are  less  obvious  physically,  and 
more  obvious  in  dress  and  occupation.  Under  such  circumstances  the 
child  learns  only  comparatively  late  to  classify  himself  sexually ;  and,  in 
consequence,  the  possibility  of  sexual  perversion  is  increased.  A  male 
child  thus  might  early  show  a  preference  for  feminine  dress  and  feminine 
play.  This  tendency  would  have  in  itself  no  sexual  meaning ;  but  the 
proclivity  might  take  so  strong  a  hold  of  the  mind  as  to  l)e  determinate 
and  serve  in  itself  to  pervert  (or  prevent  the  normal  expression  of)  the 
sexual  inclination.  There  would  be  sexual  desu"e,  but  it  would  be  guided 
and  directed  by  the  inclinations  (asexual)  previously  acquired,  provided 
opposite  influences  were  not  brought  to  bear.  Example  and  imitation  are 
factors  which  direct  the  development  of  the  child's  mind,  and  its  tastes 
are  determined  thus  before  puberty  has  awakened  sexual  feelings. 

Since  education,  example,  and  imitation  develop  in  us  all  the  secondary 
and  higher  characteristics  of  sexuality  appropriate  to  each  sex,  it  would 
seem  that  the  term  congenital  as  applied  to  sexual  perversions  should  be 
used  sparingly. 

However,  the  accepted  classification  of  psychosexual  anomalies,  in  its. 
separation  of  so-called  congenital  and  acquired  cases,  justly  recognizes  an 
important  distinction,  namely,  the  separation  of  cases  dating  back  to^ 
childhood  from  those  of  later  origin.  The  importance  of  this  differentia- 
tion depends  upon  the  fact  that  a  tendenc}^  arising  and  developing  in  child- 
hood is  apt  to  become  so  strong  and  unalterable  that  it  persists  as  a  domi- 
nant characteristic  throughout  life,  in  spite  of  all  artificial  efforts  to  correct 
or  alter  it  after  maturity.  This  is  especially  true  of  the  sexual  tendency. 
Should  a  child  develop  any  kind  of  sexual  perversion,  aside  from  the  inher- 
ent tendency  for  it  to  persist,  circumstances  would  favor  its  continuance. 
Thus  the  modesty  of  cultivated  society  prevents  the  recognition  of  such 
an  anomaly  early ;  the  affected  child  goes  on  in  the  perverse  du-ection  un- 
enlightened ;  at  last,  with  experience  only  in  the  perverse  direction,  when 
the  normal  sexual  relations  are  learned  they  are  not  comprehended,  or 
they  fail  to  give  satisfaction  equal  to  that  experienced  in  perverse  sexual 
indulgence,  and  they  make  no  impression  on  the  individual.  On  the  other 
hand,  a  sexual  perversion  acquired  late  is  far  more  subject  to  change. 


SEXUAL   CRIMES.  535 

In  siK.'li  a  case  normal  sexual  inclinations  have  been  primarily  exercised, 
and  they  continue  the  stronger ;  perversion  has  taken  place  under  pecul- 
iar circumstances,  and  with  a  restoration  of  normal  cu-cumstances  the 
normal  inclination  reasserts  itself.  Another  important  fact  in  psycho- 
sexual  pathology  is  the  relation  of  sexual  perversion  to  neuropsijrJiical  de- 
generdcj).  Observation  sh<nvs  tluit  f or  the  most  part  psyeho.sexnal  anom- 
alies are  developed  upon  a  degenerate  constitution  which  may  commonly 
be  traced  to  a  neuropathic  disposition  inherited  fi'om  anc-estors.  Tliis 
relation  must  be  given  due  consideration  in  estunating  tlie  significance  of 
any  psychosexual  abnormality. 

Par(Bsthesia  sexiialis  is  a  general  designation  covering  all  cases  of  gen- 
uine sexual  perversion.  It  signifies  a  departure  from  the  normal  direction 
of  sexual  feeling,  and  as  a  general  term  it  includes  several  distinct  varie- 
ties of  sexual  perversion,  namely,  sadism,  passinsm,  fetkhlsm,  and  contrary 
sexual  instinct  in  all  its  varieties.  Para?sthesia  sexualis  is  frecpiently  asso- 
ciated with  other  auonuxlies  of  sexual  feeling,  esj^ecially  hj-peraesthesia 
sexualis ;  and  for  the  sake  of  completeness,  l^ef ore  consideration  of  para-s- 
thesia  sexualis  in  detail,  we  may  briefly  review  these  related  sexual  anom- 
alies, which,  in  accordance  with  the  classification  of  von  Kratft-Ebing, 
may  be  divided  into  sexual  par adoxia,  sexual  ancesthesia,  and  sexual  lujper- 
a'sthesia. 

Sexual  Paradoxia. — Like  all  these  anomalies,  paradoxia  sexualis  is 
referable  to  a  cerebral  neurosis.  The  term  covers  those  manifestations 
of  sexual  desire  which  occur  during  periods  of  life  when  sexual  inclina- 
tion is  normally  absent ;  i.e.,  when  reproductive  power  has  not  been  at- 
tained, or  has  been  extinguished  as  a  result  of  advanced  years. 

The  paradoxical  expression  of  sexual  appetite  in  childhood  is  chiefly 
of  medical  interest,  especially  in  its  relation  to  neuropsychopathic  disposi- 
tion and  the  psychosexual  anomalies  of  matiuity ;  its  immediate  medico- 
legal importance  is  small,  owing  to  its  association  Avith  moral  and  legal 
irresponsibility.  Paradoxia  sexualis  manifested  during  senihty,  after  the 
sexual  glands  and  organs  have  become  functionless,  is  a  psychopathologi- 
cal  phenomenon  of  great  medico-legal  interest.  It  is  the  most  frequent 
motive  for  the  commission  of  sexual  crimes  by  old  men,  and  in  all  eases 
of  this  character  the  perpetrator  should  be  given  the  justice  of  a  psychi- 
atrical examination. 

Sexual  desire  in  old  men  is  not  in  itself  a  pathological  phenomenon. 
There  are  many  instances  of  the  retention  of  procreative  power  by  men 
up  to  a  very  advanced  age  ;  but  where  sexual  power  and  desire  have  once 
been  extinguished  in  the  course  of  advancing  years,  and  sexual  desire  is 
reawakened  and  manifested  in  ways  unknown  to  the  individual  during 
his  period  of  virility,  there  is  at  once  a  ju'esumption  that  this  change  is 
the  result  of  pathological  causes.  Accompanying  senile  sexual  desire 
there  is,  if  the  intellect  be  not  too  seriously  impaired,  recognition  of  the 
absence  of  power  to  perform  normal  sexual  acts,  and  such  victims  of 
senile  decrei)itude  are  therefore  driven  to  the  performance  of  various  acts 
as  equivalents.  In  the  impossilulity  of  obtaining  the  consent  of  ninture 
individuals  to  the  performanc^e  of  perverse  acts  with  them,  they  are  forced 
to  avail  themselves  of  others  whom,  through  ignorance  or  innocence,  they 
are^able  to  influence  or  force  into  sulunissicni.  In  this  way  children  fre- 
quently become  their  victims.  Still  such  individuals  are  not  incapable 
of  a  formal  sexual  assault  upon  more  mature  females. 


556  ^   SYSTEM  OF  LEGAL  MEDICINE. 

These  anomalous  psyeliosexiial  plienomena  are  commonly  manifested 
after  other  obvions  mental  symptoms  of  senile  organic  changes  in  the 
brain  have  become  apparent,  and  nnder  such  circumstances  the  diagnosis 
is  suffteiently  easy ;  but  in  many  cases  the  paradoxical  sexual  desire  is 
apparent  before  there  are  any  marked  signs  of  intellectual  decaj^  Even 
here  it  will  not  be  difficult  to  establish  the  pathological  character  of  the 
sexual  impulse  upon  careful  examination.  It  will  usually  be  found  that 
the  man's  moral  character  has  been  undergoing  a  more  or  less  marked 
deterioration,  as  indicated  by  changes  of  occupation,  inanner,  and  thought, 
and  by  unwonted  irritability  and  lack  of  sympathy — a  marked  intensifica- 
tion of  selfishness.  Before  dementia  has  become  pronounced  there  may  be 
sufficient  mind  to  allow  recognition  of  the  necessity  for  privacy  in  sexual 
acts,  but  with  increasing  mental  decay  all  restraining  ideas  are  lost,  and  im- 
moral acts  are  performed  impulsively  and  without  the  slightest  considera- 
tion of  consequences.  In  such  a  condition,  with  the  total  lack  of  power  to 
perform  coitus,  psychosexual  excitement  is  sure  to  lead  to  perverse  acts  as 
substitutes.  The  sexual  crimes  possible  under  such  circumstances  are  very 
numerous.  Rape  may  be  attempted  and  carried  out ;  exhibition  is  very 
frequently  indulged  in )  and  the  various  forms  of  sexual  abuse  of  children, 
aside  from  rape,  are  very  frequent.  Indecent  acts  of  various  kinds  not 
sexual  in  themselves  may  be  performed  as  equivalents,  and  even  acts  of 
cruelty  may  thus  result.  There  may  be  formal  perversion  or  inversion 
of  the  sexual  desire,  leading  to  sodomy,  or  to  pederasty,  active  or  passive. 
This  paradoxical  manifestation  of  sexual  impulse  may  also  arise  in  aged 
women,  but  in  them  it  is  less  frequent  and  of  less  medico-legal  importance. 

The  following  case  illustrates  a  senUe  attempt  at  rape  : 

X,  aged  sixty,  wife  living,  and  father  of  grown  children,  pre\T.ouslj' 
moral,  was  convicted  of  an  attempt  at  rape  on  the  person  of  a  girl  aged 
eighteen,  and  sentenced  to  imprisonment.  Examination  showed  him  to 
be  decrepit  both  physically  and  mentally.  He  looked  ten  years  older 
than  his  age.  In  confinement  he  was  given  to  religious  enthusiasm  and 
a  demented  remorse  for  his  crime.  The  circumstances  under  which  the 
attempt  was  made  clearly  showed  the  demented  lack  of  appreciation  of 
the  certainty  of  conviction  for  the  assault.  A  psychiatrical  examination 
was  not  allowed  before  conviction. 

The  following  case  is  one  of  senile  exhibition  :  * 

X,  aged  sixty,  widower,  and  father  of  a  family.  He  repeatedly  ex- 
hibited his  genitals  at  his  window  to  a  little  girl  living  opposite.  He  ac- 
knowledged the  depravity  of  his  actions,  but  could  offer  no  excuse.  He 
died  in  a  year  of  cerebral  disease. 

Often  the  sexual  offense  of  senile  dementia  consists  of  genital  manipu- 
lations. Children  are  thus  abused,  or  induced  to  fondle  the  genitals  of 
the  seducer  in  various  disgusting  ways.  Senile  sexual  excitement  may 
find  satisfaction  in  the  infliction  of  pain  {vide  Sadism),  and  thus  seek  ex- 
pression in  flagellation  and  even  lust-nmrder  (q.v.).  A  case  reported  by 
Tarnowsky  illustrates  the  possibility  of  the  most  disgusting  equivalents 
for  the  sexual  act.  An  aged  man  seized  an  opportunity  to  defecate  on  the 
exposed  bosom  of  a  woman.  During  the  act  he  experienced  a  feeling  of 
ejaculation.  The  possibility  of  senile  sexual  inversion  is  illustrated  by 
the  follomng  case  reported  by  von  Krafft-Ebing :  t 

*  Las^uge,  Umon  McdicaJc,  May,  1877.  t  rsycopathia  Scxuulls,  p.  41. 


SEXUAL   CRIMES.  557 

X,  male,  an:od  oi^-lity.  For  fourteen  moiitlis  it  had  been  noticed  tliat 
lie  manifested  aft'eetion  for  male  servants,  especijilly  for  a  boy.  He 
would  surfeit  liis  favorite  with  favors,  and  command  tliat  Ik;  be  shown 
the  greatest  res])ect.  Tlu;  acts  practiced  with  the  ])()y  and  other  male 
servants  were  exhibition,  genital  manipulations,  and  mutual  nuislurba- 
tion.     X  was  devoid  of  all  inclination  toward  the  opposite  sex. 

Sexual  Anaesthesia. — Absence  of  sexual  inclination  occiu's  as  an  orig- 
inal and  an  accjuired  anomal}'. 

Th(!  original  form  is  exceedingly  rare.  It  is  represented  l)y  the  entire 
failure  to  develop  sexual  desire  in  the  presence  of  sexual  organs  normal 
in  structure  and  function.  In  itself  it  is  a  sign  of  imperfect  development 
of  cerebral  function.  It  nuiy  be  present  without  other  indications  of 
psychical  defect,  or  it  may  be  accompanied  b}'  various  degrees  of  mental 
imperfection  up  to  idiocy.  Some  detieiency  is  more  common  than  total  ab- 
sence, and  it  is  much  more  frequently  observed  in  women  than  in  men. 
Its  direct  medico-legal  importance  is  small,  but  it  is  a  frequent  cause  of 
nuii'ital  unliappiness.  Not  infrequently  wives  manifesting  sexual  anaes- 
thesia are  also  subject  to  decided  psychopathic  tendencies. 

Acquired  sexual  aiue.sfhesia  is,  as  an  isolated  condition,  of  slight  medico- 
legal interest ;  but  as  a  factor  in  cases  of  sexual  perversion  its  relation  to 
the  latter  shoiild  be  understood.  Noi'iually,  libido  sexualis  is  dinunished 
temporarily  after  the  sexual  act,  and  it  declines  gi-adually  as  age  ad- 
vances. Libido  is  more  or  less  closely  related  to  the  functional  activity  of 
the  generative  glands  (male  and  female) ;  in  exceptional  cases,  however, 
desire  outlasts  the  functional  life  of  these  organs ;  for  example,  some 
women  retain  lively  sexual  desire  after  the  climacteric,  and  some  eunuchs 
have  been  known  to  manifest  sexual  appetite.  The  common  peripheral 
causes  of  acquired  anaesthesia  sexualis  are  castration,  degeneration  of 
the  ovaries  and  testes,  general  wasting,  chronic  intoxications,  and  sexual 
excesses  in  the  normal  nuxnner  or  in  mastiirbatiou.  Sexual  excess  in 
onanism  is  perhaps  the  nu)st  frequent  cause ;  and  in  cases  where  mastur- 
bation has  induced  anaesthesia  for  normal  sexual  stimuli  it  is  not  infre- 
quent to  have  the  sexual  impulse  find  some  perverted  manner  of  expres- 
sion, and  lead  to  acts  which  become  of  medico-legal  importance.  Indeed 
it  may  be  said  that  masturliation  is  one  of  the  most  potent  causes  of 
sexual  perversion,  and  that  through  its  effect  to  iuduce  psychical  anj^s- 
thesia  for  all  normal  sexual  stinndi.  Sexual  anaesthesia  acquired  eaily 
is  often  associated  with  mental  disease,  where  any  acts  to  which  it  might 
lead,  in  case  they  were  of  a  criminal  nature,  would  call  for  investigation 
on  the  basis  of  the  accompanying  mental  anomaly. 

Sexual  Hyperaesthesia. — This  term  signifies  a  pathological  intensifi- 
cation of  sexiial  desire.  In  the  milder  degrees  of  intensification  of  the 
sexual  inclination  it  is  always  difficult  and  often  impossible  to  satisfac- 
torily determine  whether  the  phenouuenon  is  pathological  or  not ;  in  its 
more  marked  degrees,  however,  we  have  no  troulde  in  recognizing  its 
pathological  charncter.  In  estimating  the  intinisity  of  sexual  inclination 
it  must  be  remembered  that  it  varies  much  in  individuals  as  well  as  iu 
the  sexes.  It  may  be  said  that  sexual  appetite  is  usually  proportionate 
to  the  general  physical  developnuent,  but  there  are  many  exceptions  to 
this.  Normally,  women  manifest  niTich  less  intensity  of  sexmil  inclina- 
tion thiui  do  men ;  and  therefore  when  a  wonuiu  shows  a  predominant 
.sexual  inclination  the  suspicion  that  it  is  pathological  is  at  once  excited. 


558  -i   SYSTEM  PF  LEGAL  MEDICLXE. 

Observation  shows  that  in  both  sexes  hypei-^sthesia  sexualis  is  fre- 
quents manifested,  by  persons  ha\4ng  a  neuropathic  constitution ;  this 
symptomatic  manifestation  may  be,  indeed,  the  most  obvious  sign  of  such 
a  constitutional  deficiencj'.  Von  Krafft-Ebing  points  out  very  justly 
that  in  such  individuals  satisfaction  of  the  sexual  impulse  may  become 
an  organic  necessity  and.  thus  endanger  responsibilit}'.  In  females  sexual 
desire  is  temporarily  intensified,  immediately  after  mensti-uation,  and  in 
neuropathic  women  this  normal  intensification  frequently  reaches  a 
pathological  degree.  Pathological  in  censification  of  libido  sexualis  may 
be  brought  about  by  peripheral  or  central  causes,  the  former  being  more 
frequently  operative.  Certain  drugs,  as  cantharides,  are  capable  of  ex- 
citing it.  The  j)eriod  of  the  climacteric  in  females  is  one  in  which  hj^Dcr- 
sesthesia  sexualis  may  be  markedly  exhibited,  especially  in  tLose  of  neu- 
ropathic constitution.  Sexual  hjq^er^sthesia  of  central  (cerebral)  origin 
is  most  frequently  oljserved  in  neurotic  indivdduals,  and  is  frequently- 
associated  with  hysteria  and  states  of  general  mental  exaltation. 

Where  there  is  Ini^erssthesia  sexualis  there  is  an  impulse  to  indulge 
in  some  sexual  act,  and  if  the  impulse  be  powerful  enough,  or  if  there  is 
a  simultaneous  removal  of  inhibitoiy  influences,  it  finds  expression.  The 
sexual  acts  possible  under  such  circumstances  are  coitus — which  may  take 
the  form  of  rape — mastm-bation,  pederasty,  and  bestiahty.  The  special 
fonn  of  sexual  indulgence  practiced  will,  of  coiu-se,  depend  upon  sur- 
rounding circimistances,  prevdous  habits,  and  the  individual's  moral  sense 
and  possible  moral  self-control.  As  a  rule,  hypertesthesia  sexualis  is  a 
condition  accompanying  the  various  forms  of  sexual  perversion,  and  its 
manifestation  will  be  best  illustrated  in  such  cases ;  however,  we  may 
here  cite  briefly  simj^le  cases  of  it  which  will  make  its  independent 
medico-legal  bearing  clear. 

The  following  case  is  given  by  von  Krafft-Ebing :  * 
C.  was  aiTcsted  for  an  attempt  to  rape  a  woman  aged  seventy,  whom 
he  found  alone.  Examination  of  the  culprit  showed  him  to  be  in  a  state 
of  high  nerv^ous  excitement,  and  he  gave  the  imj)ression  of  one  in  the 
incipient  stage  of  alcoholic  insanity.  There  were  still  signs  of  sexual 
excitement.  He  made  a  statement  to  the  effect  that  his  criminal  act  was 
the  result  of  an  uncontrollable  impulse  to  sexual  indulgence;  and  in 
substantiation  of  his  assertion  he  gave  the  following  history ;  .He  was 
f orty-fiA^e  years  old ;  at  the  age  of  seven  he  had  developed  a  pecuhar  par- 
tiality for  men,  and  he  fell  in  love  with  certain  men.  He  began  to  mas- 
tm-bate  at  the  age  of  fourteen;  first  intercourse  at  seventeen.  Then 
his  earher  tendency  to  sexual  inversion  disappeared.  At  that  time  he 
passed  through  a  peculiar  psychopathic  state.  He  developed  hemor- 
rhoids at  fifteen.  He  was  at  this  time  in  a  state  of  constant  sexual  ex- 
citement, which  was  temporarily  relieved  by  the  occasional  occurrence 
of  profuse  hemorrhoidal  hemorrhage.  His  sexual  excitement  he  satis- 
fied in  onanism  and  coitus.  Every  woman  he  met  excited  him ;  even 
with  his  female  relatives  he  was  unable  to  control  his  impulse,  and  thus 
often  brought  disgrace  on  himself.  He  mai-ried  at  thirty-six,  and  be- 
came a  bui'den  to  his  "wife  because  of  his  sexual  needs.  Three  years 
later  he  had  an  attack  of  mania,  and  he  was  treated  in  asylums  until  his 
forty-second  year.     His  mental  s^Tnptoms  were  those  of  reciu-rent  mania 

*  Loc.  clt.,  p.  51, 


SEXUAL   CRIMES.  .j.yj 

with  <iTC'at  soxiial  excitement.  After  his  recovery  he  still  suffered  with 
inoi-dinate  sexual  desire,  and  at  the  height  of  sexual  excitement  he  was- 
indifferent  as  to  whether  it  was  satisfied  with  human  being  or  beast. 
His  last  sexual  attack  had  followed  sexual  abstinence,  and  he  was  at  the 
time  on  his  way  to  join  his  wife  in  Vienna.  In  his  excitement  and  con- 
fusion he  had  left  the  train,  and  meeting  a  woman  had  exposed  himself 
and  sought  to  embrace  her. 

Sexual  hypera^stliesia  nuiy  also  be  numifested  intermittently  or  j^eriod- 
ieall}',  and  then  it  is  either  a  neurosis  per  se^  or  the  symptom  of  general 
mental  excitement.     (Von  Kraft't-E)jing.) 

The  following  case,  which  von  Kratt't-Ebing  *  takes  from  Trelat's  Folie 
Liieide,  is  of  great  interest  as  illustrating  pure  sexual  hyperaesthesia : 

Mrs.  V.  had  always  had  a  passion  for  men.  She  was  well-bred,  jjleas- 
ant,  and  modest,  but  a  terror  to  her  family  from  childhood  on  account 
of  her  sexual  inclinations.  She  could  not  be  left  alone  with  a  man, 
because  of  her  passion  to  have  sexual  relations  with  every  one  she  met. 
Nothing  cured  her  of  this.  Marriage  was  of  no  avail.  When  a  grand- 
mother she  attempted  to  seduce  a  boy.  Confinement  in  a  convent  did 
no  good  save  during  the  time  of  her  detention.  Banished  by  her  fumily^ 
she  earned  money  to  piu-chase  lovers.  She  was  finally  placed  in  an  asy- 
lum, where  she  died  in  her  seventy-third  year.  During  her  treatment 
there  she  showed  no  sign  of  mental  abnormality,  but  her  uncontrollable 
sexual  impulse  was  manifested  shortly  before  she  died. 

Sexual  Parassthesia. — This  term  covers  those  cases  in  which  the  sexual 
feeling  and  inclination  are  more  or  less  out  of  harmony  with  the  ntitural 
purpose  of  the  sexual  instinct.  As  already  noted,  sexual  hypera?sthesia 
is  a  frequent  accompaniment  of  sexual  partesthesia,  and  it  then  becomes 
the  active  factor  in  inducing  the  affected  individual  to  indulge  in  per- 
verse sexual  acts.  The  sexual  acts  prompted  by  the  association  of  tliese 
two  pathological  conditions  are  the  most  important  of  all  sexual  crimes, 
from  a  medico-legal  standpoint;  and  it  becomes  of  the  gTcatest  im- 
portance to  determine  in  how  far  such  crimes  are  the  results  of  disease 
or  vice. 

The  recent  establishment  of  paresthesia  sexualis  on  a  pathological 
foundation  makes  it  imperative  to  take  this  aspect  of  the  matter  int» 
consideration.  It  nmj  be  said  at  the  outset  of  such  inquiries  that  the 
question  of  the  ]3athological  basis  of  a  perverse  sexual  act  can  in  no  case 
be  determined  by  the  net  per  se;  no  more  than  can  a  case  of  insanity  be 
diagnosticated  scientifically  by  means  of  some  isolated  mental  symptom. 
The  sexual  acts  springing  from  disease  and  those  prompted  by  vice  may 
be  in  many  cases  identical.  The  distinction  between  i)athological  and 
vicious  sexual  acts  is  to  be  made  only  upon  a  thcu-ough  understanding 
of  the  nature  of  the  motive  of  which  the  specific  sexual  act  is  the  expres- 
sion ;  and  this  can  only  be  accomplished  by  a  thorough  investigation  of 
the  histor}"  and  the  physical  and  mental  pe<?uliarities  of  the  individual 
— an  inquirj^  which  must  often  be  extended  to  educational  influences  that 
may  have  been  effective,  and  to  ancestry,  just  as  in  all  cases  of  neuro- 
psychical  maladies. 

The  normal  direction  of  sexual  feeling  is  toward  the  opposite ;  but 
sexual  desire  may  be  so  altered  in  direction  that  the  sexual  inclination  is 

*  Loc.  cit.,  p.  55. 


560  ^   STSTJSM   OF  LEGAL  MEDICLNE. 

actually  inverted  and  becomes  directed  toward  tlie  same  sex.  Sucli  an 
alteration  of  sexual  feeling  is  a  variety  of  sexual  paraesthesia,  a  sexual 
perversion ;  but  owing  to  its  distinctness,  and  to  separate  it  from  other 
varieties  of  perversion,  it  is  best  to  designate  it  as  sexual  inversion  or 
contrary  sexual  instinct.  Moreover  it  is  found  that  contrary  sexual  in- 
stinct is  subject  to  various  perversions,  like  the  normal  sexual  instinct. 
Wliere  sexual  feeling  is  normal  in  direction  it  is  called  heterosexual; 
where  it  is  dii'ected  toward  the  same  sex  it  is  called  homosexual.  For 
convenience  we  may  consider  the  sexual  perversions  that  occur  apart 
from  sexual  inversion,  remembering  that  these  anomalies  may  occur  in 
conjunction  with  the  latter. 

Sadism  is  the  term  applied  to  sexual  lust  that  finds  expression  in  the 
infliction  of  cruelty  on  others.  This  word  is  derived  from  the  name  of 
a  writer  of  obscene  fiction,  the  Marquis  de  Sade,  whose  theme  ^yas  lust 
and  cruelty.  A  synonym  for  sadism,  proposed  by  von  Schrenek-Notz- 
ing,*  is  active  algolagny,  which  is  derived  from  Greek  words  signifying 
love  of  pain.  The  perverse  sexual  gratification  in  the  infliction  of  cruelty 
may  affect  male  or  female,  but  it  is  far  more  commonly  observed  in  males. 
This  pathological  association  of  sexual  lust  and  pleasure  in  the  infliction 
of  pain,  with  its  predominance  in  males,  is  to  be  imderstood  only  by 
means  of  psychophysiological  associations.  Psychosexual  emotion  and 
the  emotion  (anger)  which  normally  impels  to  injury  of  another  are  alike 
in  their  objective  direction  and  in  their  dependence  upon  intense  excite- 
ment of  the  psychomotor  sphere.  Owing  to  this  common  characteristic 
and  this  common  dependence,  there  is  a  very  close  association  between 
the  acts  of  love  at  its  greatest  intensity  and  the  acts  of  anger.  Within 
physiological  limits  intense  excitement  during  the  sexual  act  is  thus  apt 
to  lead  to  the  performance  of  acts  which  are  ordinarily  expressive  of 
anger ;  and,  on  the  other  hand,  the  objective  activity  of  angry  emotion 
is  apt  to  excite  lustful  feeling.  The  male  sexual  role  is  the  aggressive 
one,  and  male  sexual  excitement  is  more  intense  than  that  of  the  fe- 
male ;  hence  the  greater  frequency  of  sadism  in  the  male.  This  psycho- 
physiological association  reaches  pathological  intensity  and  then  finds 
expression  in  acts  of  cruelty  of  various  degrees  up  to  the  commission  of 
murder.  It  is  not  always  necessary  that  actual  pain  be  inflicted;  often 
an  act  symbolic  of  cruelty  is  sufficient  to  satisfy  the  individual.  Sadistic 
acts  also  vary  in  their  relation  to  the  sexual  act.  They  may  be  indulged 
in  at  the  height  of  sexual  excitement  during  the  sexual  act;  after  the 
sexual  act,  when  this  has  not  diminished  the  primary  psychosexual 
excitement;  before  the  sexual  act  as  a  stimulus  to  virility,  when  virile 
power  is  diminished ;  and  to  induce  ejaculation,  when  this  is  imj)ossible  in 
coitus. 

Sexual  hypersesthesia  is  always  the  basis  upon  which  sadistic  acts 
rest.  Practically  it  is  found  that  most  persons  manifesting  sadism  are 
originally  more  or  less  psychopathic.  Von  Krafft-Ebing  is  inclined  to  be- 
lieve that  this  perversion  is  always  congenital ;  but  such  an  assiunptiou 
does  not  seem  necessary.  In  psychopathic  individuals,  where  there  is 
frequently  a  hypersensitive  nervous  organization,  psychical  associations 
are  most  readily  formed,  and  substitution,  primarily  at  least,  most  read- 
ily occurs ;  hence  in  such  persons  there  would  be  special  proclivity  to  the 

*  Suggestions  liy.  Tlicrapic,  1892. 


SEXUAL   CRIMES.  5 til 

development  of  an  intense  and  lasting:  association  of  lust  with  acts  of 
cruelty,  to  which  they  are  predisposed  by  the  readiness  with  which  they 
react  with  intense  psychomotor  excitement  to  stimuli  normally  inade- 
quate. However  we  seek  to  explain  this  association  of  lust  and  cruelty 
theoretically,  the  actual  association  is  most  clearly  shown  by  recorded 
cases,  and  the  monstrous  crimes  it  leads  to  make  this  particular  form  of 
sexual  perversion  of  the  <>Teatest  medico-legal  interest. 

Lust=murder. — Only  murder  comnutted  in  association  with  sexual 
excitement  or  for  sexual  <>Tatification  is  properly  lust-murder.  The  lust 
may  also  lead  to  horrible  mutilation  of  the  body  after  the  death  of  the 
victim.  Lombroso*  reports  the  case  of  a  man  named  Grassi,  who  was 
suddenly  seized  with  a  sexual  desire  for  a  relative.  When  she  resisted 
he  stabbed  her  several  times  with  a  knife,  and  also  her  father  and  uncle, 
who  souglit  to  restrain  him.  He  then  repaired  to  a  prostitute  to  cool  his 
sexual  desire ;  returning',  he  killed  his  father  and  slaughtered  several 
oxen  in  their  stalls.  The  case  of  Andreas  Bichel,  reported  by  Feuerbach, 
is  also  instructive.  He  killed  and  dissected  prostitutes.  Concerning  one 
of  his  victims  he  said :  "  I  opened  her  breast  and  cut  through  the  fleshy 
parts  of  her  body  with  a  knife.  I  then  arranged  her  body  as  a  butcher 
does  a  beef.  .  .  .  "VMiile  opening  the  body  I  was  so  greedy  that  I  trem- 
bled and  could  have  cut  out  a  piece  and  eaten  it."  Another  case  is  that 
of  a  man  who  was  examined  by  Lasegue,  Brouardel,  and  Motet,  and  exe- 
cuted :  Menesclou,  aged  twenty,  murdered  a  girl  aged  four.  One  of  her 
forearms  was  found  in  his  pocket.  The  head  and  entrails,  in  a  half- 
burned  state,  were  taken  from  the  stove,  and  other  parts  of  the  body 
were  found  in  the  water-closet,  but  the  genitals  could  not  be  found.  M. 
became  embarrassed  when  questioned  about  the  latter.  His  sexual  his- 
tory was  to  the  effect  that  he  did  not  indidge  in  intercoui'se  with  women, 
but  practiced  mastui-bation  and  sodomy.  His  mother  and  an  uncle  were 
insane.     M.'s  own  history  was  otherwise  that  of  a  psychopath. 

How  unbridled  lust  may  lead  to  anthroj^ophagy  is  shown  by  the 
following  case,  reported  by  Gorget:  L.,  aged  twenty-foui*,  caught  a  girl 
of  twelve  in  the  woods  and  violated  her.  He  mutilated  her  genitals,  tore 
out  her  heart  and  ate  of  it,  drank  her  blood,  and  buried  the  remains. 
He  confessed  his  crime  and  was  executed. 

In  some  cases  sexual  violation  is  omitted,  the  mutilation  of  the  vic- 
tim being  a  full  sexual  equivalent.  The  case  of  Verzeni,  reported  by 
Lombroso,  was  such  an  one.  He  made  several  unsuccessful  attempts  to 
strangle  women,  and  in  the  same  way  murdered  three  young  women. 
The  confession  of  this  degenerate  creature  is  especially  interesting  for 
the  light  it  throws  ui)on  this  association  of  lust  and  cruelty.  The  com- 
ndssion  of  the  nnirders  by  strangulation  gave  him  an  intense  lustful 
pleasure,  accompanied  by  erection  aiid  ejaculation.  He  experienced 
sexual  pleasiu'e  immediately  upon  grasping  the  neck  of  his  victim. 
Ordinarily,  merely  choking  his  victim  was  sufficient  to  induce  sexual 
pleasure  ;  but  if  the  orgasm  were  delayed  he  continued  the  strangulation 
until  death  ensued.  In  one  instance  he  had  found  great  satisfaction  in 
sucking  his  victim's  blood,  and  he  tore  out  a  piece  of  the  calf  to  roast  and 
eat  at  home,  but  hid  it.  He  delighted  in  smelling  and  touching  the 
clothes  and  intestines.     Wliile  in  the  act  he  was  in  a  perfect  furor  of 

*  The  Criminal. 


562  ^   SYSTEM  OF  LEGAL  MEDICINE. 

excitement  and  oblivions  to  everything  else.  The  female  genitals  were 
a  matter  of  indifference  to  him,  and  he  never  had  inclination  for  normal 
sexnal  indulgence.  His  perverse  inclination  was  first  shown  in  his  twelfth 
year,  when  he  experienced  a  peculiar  feeling  of  pleasure  while  wringing 
the  necks  of  chickens.  He  did  this  frequentl}^  with  no  other  purpose 
than  the  induction  of  sexual  excitement,  and  the  early  accidental  asso- 
ciation remained  determinate  and  became  an  uncontrollable  im23ulse. 
He  was  sentenced  for  life. 

Mittilafion  of  the  dead  bod}^  out  of  lust  is  allied  to  actual  lust-murder 
in  that  the  mere  act  of  mutilation  of  a  corj^se  affords  the  sexual  gratifi- 
cation that  in  lust-murder  is  attendant  upon  the  actual  infliction  of  pain. 
It  is  an  act  of  symbolic  sadism,  performed  by  a  sadistic  individual  whose 
moral  sense  is  still  strong  enough  to  restrain  him  from  doing  violence 
to  the  living  female.  This  form  of  sadism  may  be  combined  with  an 
inchnation  to  actual  sexual  gratification  with  the  body.  The  case  of 
Sergeant  Bertrand  is  a  celebrated  instance.  He  was  of  delicate  consti- 
tution and  peculiar  character.  At  the  age  of  thirteen  his  sexual  desire 
became  manifest  and  he  began  to  practice  mastiu'bation,  in  the  act  sur- 
rounding himself  with  imaginary  women.  He  would  fancy  having  in- 
tercourse with  them  and  then  killing  them;  then  he  would  think  of 
violating  the  corj)ses.  At  last  he  experienced  the  desire  to  make  his 
fancies  actual.  First  he  made  use  of  the  bodies  of  animals,  opening 
the  abdomen  and  tearing  out  the  entrails  while  masturbating ;  next  he 
killed  and  mutilated  dogs ;  and  finally  he  came  to  exhume  female  corpses 
to  mutilate  them  and  masturbate.  On  three  occasions  he  first  performed 
the  sexual  act  on  the  bodies  of  females,  but  he  never  omitted  subsequent 
mutilation,  which  was  the  only  act  that  gave  complete  gratification. 

Allied  to  this  symbolic  sadism  is  true  tiecropMlia,  in  which  a  female 
corpse  is  preferred  to  a  living  woinan  for  the  performance  of  coitus.  In 
such  cases  there  is  not  pure  sadism,  but  it  would  seem  that  the  idea  of 
feminine  submission,  which  is  so  strong  a  sexual  stimulus  for  the  male, 
becomes  so  intensified  as  to  see  its  objective  perfection  only  where  there 
is  no  possibihty  of  resistance,  as  in  death.  StiU  such  eases  may  also  be 
dependent  upon  feticMsm  (q.v.),  i.e.,  pathological  association  of  first  sex- 
ual excitement  and  the  idea  of  a  female  corpse. 

The  sadistic  impulse  is  often  expressed  in  acts  of  cruelty  that  stop 
short  of  murder  or  very  serious  bodily  injury  of  the  victim.  Lust  is 
experienced  in  the  mere  infliction  of  pain  or  at  the  sight  of  blood.  The 
Marquis  de  Sade  took  pleasure  in  coitus  only  when  he  could  draw  blood 
on  his  consort  by  pricking  her ;  and  a  man  mentioned  by  de  Boismont 
forced  his  consort  to  make  her  genitals  bloody  by  means  of  leeches  be- 
fore coitus.  The  latter  instance  may  have  been  a  pure  case  of  feficlihm 
originating  in  an  early  coitus  with  a  menstruating  woman.  The  slighter 
bodily  injuries  inflicted  on  women  by  sadists  for  the  purpose  of  sexual 
gratification  vary.  It  is  frequent  to  observe  a  desire  to  draw  blood  ;  but 
flagellation  of  the  female  often  sufiftces. 

It  is  to  be  noted  that  in  all  the  cases  of  sadism  reported  in  literature 
the  subjects  have  been  more  or  less  markedly  psychopathic ;  there  has 
always  been  observed  a  basis  of  hypera^sthesia,  upon  which  the  perver- 
sion has  been  developed  by  accidental  association  of  ideas.  The  varia- 
tions in  the  manner  of  expression  of  the  sadistic  iuipidse  show  liow  much 
it  is  determined  by  accident  of  experience.     With  an  original  psycho- 


SEXUAL   CHIMES.  5(j;j 

patliic  basis  and  sexual  liyperiTPstlicsia  the  conditions  are  favoral)le  for 
th(^  development  of  sadism,  as  they  are  for  the  develoi)ment  of  all  other 
forms  of  psyehosexual  perversion. 

The  ease  of  a  young-  man  reported  by  von  Kraft't-Ebing-  ilhistrates  lust- 
ful pleasure  at  the  sight  of  blood.  The  patient  reniemhcfed  his  lustful  de- 
light at  the  siglit  of  blood  as  early  as  his  tenth  year.  He  cut  and  prieked 
himself  to  gnin  tliis  pleasure.  The  sight  of  tlie  bleeding  linger  of  a  female 
gave  his  im[)ulsc  objective  direction,  and  he  nuisturbated  while  reveling 
in  the  fancy  of  bleeding  girls.  Finally  his  sadistic  f.uicy  extended  to 
the  most  horrible  slaughter  of  human  beings.  The  act  of  masturl)ation 
banished  su(;li  ideas.  He  was  alwa^^s  able  to  keep  himself  from  attem})t- 
ing  to  make  his  fancies  actual.  Neuropathic  though  he  was,  his  sadistic 
ideas  were  finally  replaced  by  natural  sexual  indulgence.  The  girl-stab- 
ber  of  Bozen  was  a  man  who  destroyed  his  sexual  powers  by  masturba- 
tion, and  finally  developed  a  substitute  for  coitus  in  the  act  of  stabbing 
with  a  knife  the  girls  he  met  on  the  street.  Ilis  satisfaction  was  intensi- 
fied l)y  the  sight  of  blood  on  the  blade.  A  similar  case  is  reported  from 
Augsburg.  The  offender  had  stabbed  about  fifty  girls,  but  was  always 
careful  to  avoid  doing  serious  injury.  He  also  found  sexual  gratification 
in  looking  at  his  collection  of  knives,  swords,  etc.  A  case  reported  by 
Dr.  Moll  is  an  instance  in  which  flagellation  of  the  female  nates  and 
liumiliation  of  the  female  were  substitutes  for  the  sexual  act. 

The  sadistic  impulse  may  be  directed  only  to  humiliation  of  the 
female,  and  thus  find  expression  in  acts  of  defilement  of  the  female  j^er- 
son.  Frequently  this  defilement  is  of  the  most  disgusting  charactei- — 
with  urine,  faeces,  etc.  It  seems  highly  probable  that  the  motive  which 
leads  to  the  defilement  of  women  by  ink,  etc.,  is  a  sadistic  impulse ;  at 
least  all  sucli  cases  should  hereafter  be  examined  with  a  view  to  discover 
any  possible  sexual  factor  where  the  per^jeti-ators  are  men  and  their  vic- 
tims women.  The  cutting  off  of  women's  hair  by  force  or  stealth  may 
possibly  have  some  relation  to  sadism,  but  mo]-e  frequently  it  is  to  l)e 
referred  to  erotic  fetichism,  which  is  described  later. 

The  literature  shows  that  there  maybe  merely  a  si/DthoJic  satisfaction 
of  the  sadistic  imjiulse.  Thus  the  sexual  gratification  souglit  may  be 
found  in  acts  and  situations  which  suggest  the  infliction  of  i)ain  or  hu- 
miliation, but  in  which  there  is  no  actual  suffering.  In  such  cases  the 
mere  idea  of  suffering  endured  by  the  passive  person,  suggested  b}^  a 
situation  artificially  created,  suffices  to  give  sexual  satisfaction.  Cases 
of  this  kind  can  seldom  give  cause  for  medico-legal  investigation,  but 
where  such  situations  were  forced  on  a  person  legal  questions  might 
arise,  as  in  a  case  reported  by  von  Krafft-Ebing,  where  a  certain  Aus- 
trian count  was  convicted  of  giving  ])ublic  offense  by  forcing  a  young 
girl  who  accompanied  him  into  a  pul)lic  garden  to  kneel  down,  implore 
him  with  folded  hands,  and  lick  his  boots,  at  the  same  time  demanding 
that  she  actuallj''  kiss  him  ad  wtfes. 

The  sadistic  inclination  may  be  directed  toward  any  living  ol^ject, 
whether  the  affected  individual  is  aware  of  its  sexual  coloring  or  not. 
Thus  there  have  been  many  cases  of  sadistic  whipping  of  children  by 
male  teachers ;  and  the  torture  of  animals  has  not  infrequently  been 
found  to  depend  upon  sexual  gratification  experienced  in  this  wanton 
infliction  of  cruelty.  In  young  persons  innocent  of  knowledge  of  the 
sexual  relations  the  latter  tendency  nuiy  be  indidged  with  unconscious- 


56i  A   SYSTEM  OF  LEGAL   MEDICIXE. 

ness  of  its  true  significance  ;  in  more  experienced  men  it  may  be  practiced 
as  a  substitute  for  tlie  satisfaction  experienced  in  cruelty  practiced  on 
females.  Von  Ki-aift-Ebing  regards  cases  in  which  the  mere  sight  of 
blood,  death,  etc.,  excites  sexual  feeling  as  instances  of  such  original  con- 
stitution of  the  vita  sexualis  that  the  relation  between  these  impressions 
and  lustful  feeling  is  a  dii'ect  or  immediate  one ;  but  to  exclude  patho- 
logical association,  even  in  these  cases,  is  impossible ;  and  it  seems  su- 
perfluous to  assume  the  existence  of  an  unnecessary  factor  to  explain 
the  phenomenon. 

Though  sadism  is  distinctly  foreign  to  the  psychical  character  of 
women,  it  is  occasiouall}'  observed  in  them.  The  tendency  of  women  to 
bite  at  the  height  of  sexual  excitement  is  well  known,  and  that  this  may 
become  intensified  to  a  pathological  degree  is  illustrated  by  the  case  re- 
ported by  Moll,  where  a  young  wife  found  her  most  intense  pleasure 
in  biting  her  husband  until  the  blood  came,  and  who  was  best  satisfied 
if  she  bit  her  husband  and  he  bit  her.  As  von  Kralft-Ebing  points  out, 
many  of  the  Messalinas  of  history  were  celebrated  for  their  lust  and 
cruelty ;  and  in  some  of  these  instances  the  conditions  suggest  that  there 
was  complete  inversion  of  the  feminine  character,  with  excessive  develop- 
ment of  the  sexual  characteristics  normal  to  men. 

In  order  to  prove  the  sadistic  natui'e  of  acts  of  cruelty  it  is  always 
necessary  to  demonstrate  distinctly  their  association  with  true  sexual 
excitement.  We  know  that  cruelty  is  a  very  frequent  manifestation,  and 
that  it  is  ordinarily  an  independent  psychological  phenomenon ;  there- 
fore it  cannot  be  j^resumed  that  the  sexual  factor  is  operative,  save  in 
those  cases  where  peculiar  circumstances  indicate  the  existence  of  this 
remarkable  pathological  association.  Where  atrocious  or  peculiar  acts 
of  crueltj^  can  be  explained  upon  no  gi'ound  of  sane  motive,  and  the  in- 
dividual is  to  aU.  intents  sane,  there  would  be  some  reason  to  suspect  the 
hidden  influence  of  a  sexual  impulse,  more  especially  if  the  acts  were  in 
an}'  way  related  to  sexual  ideas. 

Passivism. — This  terin  is  applied  to  a  psychosexual  condition  that  is 
the  counterpart  of  sadism  :  sexual  gratification  is  sought  and  experienced 
in  suffering  personal  pain  or  \-iolence,  or  theii'  psychological  ecpiivalents, 
at  the  hands  of  a  person  of  the  oppo.site  sex.  In  this  perversion  of  the 
sexual  instinct  the  idea  of  subjection  to  the  will  of  another  becomes  the 
most  intense  stimulus  to  sexual  feeling,  to  the  partial  or  entu-e  exclusion 
of  all  normal  stmiuli.  "V^Hiere  this  subjection  is  experienced,  sexual 
orgasm  is  induced  partially  or  completely. 

Passivism  is  most  striking  when  it  is  exhibited  by  men  ;  for  it  is  to 
be  regarded  as  one  of  the  psychical  characteristics  of  women,  whose 
sexual  role  is  physiologically  a  passive  one,  with  which  the  idea  of  sub- 
jection to  the  masculine  will  is  a  natural  psychical  association.  Daily 
experience  is  sufficient  to  show  that  woman  finds  her  completest  sexual 
satiety  in  being  sul^jected  to  the  masculine  sexual  domination,  and  the 
degree  to  which  this  characteristic  is  exhibited  by  females  within  reason- 
able limits  may  be  taken  as  a  measure  of  their  femininity.  Such  a  char- 
acteristic manifested  by  a  man,  however,  is  strikiiigly  abnormal,  and  it 
can  but  be  regarded  as  one  varietj^  of  perversion  on  the  way  to  comjjlete 
jisychosexual  inversion.  However,  the  many  cases  thus  far  observed  in 
men  have  been  but  infrequently  associated  with  fully  developed  sexual 
inversion ;  as  a  rule,  men  thus  affected  exj)erience  a  desii-e  for  subjection. 


SKXIAL    CHIMES.  OG.J 

humiliation,  uiid  abuse,  going-  to  tlio  extent  of  violence  and  cruelty,  at 
the  hands  of  women.  With  this  thei'c  nuiy  he  various  degi-ees  of  imp.iir- 
ment  of  virility  up  to  eompleti^  ]>syeliieal  impotence.  Tlie  satista(;tion 
of  this  strange  sexual  inclination  is  usually  sought  l)y  indueing  women 
to  perform  the  ])art  necessary  to  insure  satisfaction :  prostitutes  are 
hired  to  perform  flagellation  or  to  carry  out  various  cc^medies  in  which  the 
individual  is  placed  in  the  role  of  one  subjected  to  the  grossest  violence 
and  indecencies,  or  one  humiliated  by  a  mistress  to  an  extreme  degree. 

Von  Krafft-Ebiug  regards  cases  of  ]>assivism  as  psychol()<iically  distinct 
from  cases  of  so-called  sini[)le  tlagellation.  Pleasure  in  being  fhigellated 
may  be  something  quiti^  different  from  i)assivism.  Passivism  is  essen- 
tially a  psychosexual  anonmly  of  early  origin  in  the  life  of  the  individ- 
ual; j>l»'<i*s^^i"6  in  being  flagellated  nuiy  arise  secondarily  as  a  result  of 
cultivation,  through  experience  of  its  reflex  effect  or  as  a  stimulus  to  sex- 
ual powers  weakened  by  prolonged  excesses  in  normal  venery  or  onan- 
ism. Cases  of  passivism  thus  far  reported  lead  to  the  conclusion  that 
this  psychical  peculiarity  is  a  congenital  characteristic  in  a  certain  num- 
ber of  instances.  This  conclusion  is  I'cached  niainl}^  through  a  study  of 
the  facts  presented  b}^  the  autobiographies  of  such  individuals ;  l)ut  it 
must  always  l)e  remembered  that  statements  made  by  mature  indiWduals 
(U)ncerning  events  of  their  early  childhood  can  but  rarely,  if  at  all,  be 
freed  from  unconscious  errors  of  memory ;  and  it  would  seem  that  to 
prove  the  congenital  origin  of  such  an  anomaly  merely  by  statements 
which  are  so  confessedly  open  to  the  possibihty  of  being  unintentionally 
erroneous,  especially  in  the  face  of  so  many  cases  where  such  anomalies 
can  be  shown  to  be  acquired,  is  far  from  being  strictly  scientific.  Further- 
more, in  many  cases  of  pure  passivism  the  anomaly  is  purely  psychical, 
and  finds  its  field  of  activity  only  in  the  imagination,  realization  of  the 
imagined  situation,  with  suffering  of  punishment,  being  attended  only 
with  pain  and  no  sexual  satisfaction  wdiatever.  To  account  for  such 
cases  by  assuming  an  inborn  idea,  or  material  substratum  for  the  spon- 
taneous origin  of  such  an  idea,  independently  of  experience,  is  to  do  vio- 
lence to  scientific  methods  of  observation  and  advance  into  the  realm  of 
pure  and  unprofitable  speculation. 

Passivism  often  occurs  in  association  with  sadism,  and  e\'idence  of 
its  existence  in  a  given  case  might  be  of  value  as  indicative  of  the  exist- 
ence of  suspected  sadism  where  the  latter  might  be  of  medico-legal  im- 
portance. Passivism  is  of  much  less  direct  medico-legal  interest  than 
sadism,  for,  in  the  natui-e  of  its  t(mdencies,  it  can  seldom  lead  to  acts 
that  will  bring  the  affected  individual  within  the  \T.ew  of  the  law.  How- 
ever, there  are  several  possible  results  to  Avhich  passivism  may  lead  that 
may  call  for  medico-legal  investigations.  Thus  it  is  conceivable  that  a 
passivist  might  cause  himself  to  l)e  subjected  to  violence  that  might 
result  in  his  serious  injury  or  death,  and  that  through  accident  or  unin- 
tended severity  in  the  activ'C  party  ;  en-,  concealing  his  anomaly,  he  might 
seek  legal  damages  at  the  hands  of  the  person  he  had  hired  to  nuiltreat 
him.  That  serious  accidental  injury  inight  occur  in  this  waj'  will  be  un- 
derstood when  it  is  remembered  thaf  this  pleasure  in  pain,  ])unishment, 
and  abuse  is  satisfied  in  many  violent  procedures.  Thus  a  ]iassivist  may 
find  satisfaction  in  having  his  naked  person  flagellated  vd\\\  a  heaAy 
whip ;  in  being  trod  upon  by  poAverf  ul  women  wearing  heavy  shoes ; 
in  being  hanged  in  farce,  etc. 


56G  ^   SYSTUM  OF  LEGAL  MEDICINE. 

Passhdsm  is  frequently  combiued  witli  some  variety  of  fetichisin, 
especially  that  which  has  for  its  object  female  shoes.  In  some  cases  the 
individuals  are  affected  with  larv^ated  passi\dsm.  Here  the  idea  of  hu- 
miliation is  satisfied  in  personal  subjection  to  the  most  disgusting  and 
indecent  treatment  at  the  hands  of  women.  These  cases  are  a  countei-- 
part  of  symbolic  sadists.  The  most  disgusting  class  of  this  variety  find 
satisfaction  in  Ijeing  defiled  in  various  ways  by  feminine  excrement,  etc. 

Erotic  Fetichism. — Just  as  sadism  and  passivism  can  be  regarded 
as  pathological  exaggerations  of  psychical  characteristics  normal  to  the 
majority  of  persons,  so  can  the  relationship  of  erotic  fetichism  be  traced 
back  to  normal  or  physiological  sexual  preferences.  In  any  case  of  dis- 
ease it  is  well-nigh  impossible  to  establish  the  dividing-line  that  marks 
the  departure  from  health ;  so  in  erotic  fetichism  it  is  sometimes  difficult 
to  determine  where  physiological  phenomena  of  sexual  preference  have 
become  pathological  erotic  fetichism.  Technically,  erotic  fetichism  sig- 
nifies a  psychosexual  peculiarity  Ijy  virtue  of  which  the  indi"\ddual  exhib- 
iting it  finds  sexual  satisfaction  more  or  less  complete  in  objects  which 
under  physiological  conditions  are  incapable  of  affording  sexual  gi-atifi- 
cation. 

Physiologically,  the  characteristic  marks,  physical,  mental,  and  arti- 
ficial, of  each  sex  come  to  have  a  psychosexual  meaning  for  the  opposite 
sex,  and  on  this  basis  is  developed  that  endless  variety  of  individual  sex- 
ual preferences  wliich  we  observe  in  men  and  women.  When  this  sexual 
preference  has  attained  such  force  or  particularity  of  expression  as  to  be 
in  any  degree  exclusively  directed  toward  an  object  which  can  normally 
serve  as  merely  a  step  in  the  jDlay  of  sexual  attraction,  and  when  this 
affords  complete  sexual  satisfaction  by  the  side  or  to  the  exclusion  of 
the  normal  means  of  sexual  satiety,  the  preference  has  become  a  patho- 
logical phenomenon  and  is  an  example  of  erotic  fetichism.  This  display 
of  sexual  preference  may  have  for  its  object  the  physical  (corporeal) 
characteristics  of  the  opposite  sex  or  objects  artificially  associated  ■^dtli 
them  by  custom,  such  as  articles  of  wearing-apparel ;  in  still  other  cases 
the  object  ginning  erotic  pleasure  may  have  no  relation  to  the  opposite 
sex. 

Erotic  fetichism  is  regarded  by  all  authorities  as  an  acquu*ed  anom- 
aly ;  but  it,  like  all  the  sexual  perversions,  is  closely  related  to  a  psy- 
chopathic constitution,  and  for  the  most  part  this  constitutional  weak- 
ness is  inherited.  Erotic  fetichism  may  arise  in  cases  of  mental  disease. 
Owing  to  this  relation  to  a  constitutional  psychopathic  deficiency,  erotic 
fetichism  is  often  but  one  of  various  sexiial  anomalies  exhibited  by  the 
individual ;  thus  it  occurs  with  sadism,  passivism,  and  contrary  sexual- 
ity. The  explanation  offered  for  the  origin  of  erotic  fetichism  is  that  of 
early  psychical  association.  Where  sexual  feeling  is  exclusiA^ely  directed 
toward  some  object  normally  incapable  of  exciting  lustful  pleasure,  it  is 
presumed  that  the  primary  experience  of  lustful  feeling  has  occurred 
simultaneously  with  some  strong  mental  impression  of  that  particular 
object,  and  tiiat  this  initial  association  remained  determinate  for  the 
future  vita  sexualis.  In  man}"  recorded  cases  it  has  been  possible  to 
demonsti'ate  this  mode  of  origin  beyond  all  doubt;  its  frequenc}'  in 
neuropathic  persons  is  accounted  for  by  the  fact  that  in  such  indivdduals 
the  awakening  of  sexual  instinct  is  frequently  early,  and  thus  associations 
are  formed  which  have  but  imperfect  relation  to  normal  sexual  activities 


HEX  r A  I.    CRIMES.  5C7 

becjiuso  the  child  is  more  or  less  ig-norant  of  the  true  sexual  relations. 
The  persisteuee  of  sueli  an  early  association  is  in  great  measure  depend- 
ent upon  the  fac^t  that  early  })sychieal  associaticnis  are  the  deepest  and 
most  enduring.  Erotic  fetichisni  may  lead  to  the  commission  of  crime, 
and  therefore  it  is  of  much  medico-legal  interest.  The  recorded  cases 
of  erotic  feticliism  are  in  nuiles,  thougli  the  p()ssil)ility  of  female  fetich- 
ism  is  to  be  remeiuhei'ed. 

Body=fetichism. — It  is  convenient  to  consider  under  this  term  those 
cases  of  erotic  fetichisni  where  the  object  affording  sexual  gratification 
is  some  physical  peculiarity  of  the  female.  Nonnally  men  are  sexmdly 
attracted  by  feminine  peculiarities  of  person,  such  as  the  eyes,  the  hands, 
the  feet,  the  hair,  the  bust,  and  other  sexual  marks  of  femininity ;  and 
any  of  these  may  become  the  particular  pathological  fetich.  The  deter- 
mimition  whether  such  a  sexual  preference  is  reall}'  pathological  is  to  be 
made  by  its  relation  to  the  activity  of  the  sexual  functions.  If  the  ob- 
ject of  erotic  feticliism  constitutes  a  sine  qua  non  in  some  relati(m  for 
normal  sexual  gratification,  the  case  may  be  unhesitatingly  jtronounced 
pathological ;  and  there  can  be  no  doubt  of  the  pathological  nature  of 
cases  in  which  the  object  giving  sexual  pleasure  occupies  the  sexual 
attention  entirely  to  the  exclusion  of  all  other  sexual  ideas.  In  cases 
of  the  latter  kind,  Avoman  sinks  to  insignificance  as  a  representative  of 
sex,  and  the  sexual  act  loses  or  has  no  meaning,  while  sexual  pleasure 
is  found  only  in  some  physical  or  ideal  relation  with  the  particular 
object.  It  is  the  compai-ative  or  absolute  exclusion  of  the  action  of 
nornuxl  sexual  stimuli  by  the  jjarticular  object  of  sexual  desire  that  is 
the  measure  of  disease.  The  female  hand  is  frequently  the  object  of 
sexual  preference,  but  hand-fetichists  are  seldom  led  to  acts  which 
attain  medico-legal  importance.  The  concentration  of  sexual  interest 
on  the  feminine  hand  is  entirely  like  that  manifested  in  other  cases  of 
which  illustrations  follow.  The  greatest  medico-legal  interest  attaches 
to  those  cases  of  body-fetichism  in  which  the  particular  object  of  sexual 
interest  is  capable  of  easy  i-enu:)val,  like  the  hair.  It  is  conceivable,  how- 
ever, that  cases  might  arise  in  which  for  the  sake  of  entire  possession  of 
the  hand,  the  foot,  etc.,  of  a  fenuile,  the  feticliist  miglit  resort  to  acts  of 
a  criminal  miture ;  for  example,  a  combination  of  hand-fetichism  and 
sadism  might  lead  to  murder,  or  to  the  mutilation  of  corpses,  for  the 
possession  of  the  member. 

The  following  case,  reported  in  the  Annales  d'Hi/gihie,  April.  1890,  and 
cited  by  von  Krafft-Ebing,*  will  clearly  illustrate  the  nature  of  erotic 
feticliism  and  the  nature  of  the  crimes  to  which  it  may  lead : 

August  28,  1889,  1*.  was  arrested  at  the  Trocadero,  Paris,  in  the  act 
of  robbing  a  young  girl  of  her  hair  by  cutting  it  from  her  head.  He 
had  the  hair  in  his  hand  and  also  the  scissors  with  which  he  had  cut  it 
oft'.  He  explained  his  act  by  asserting  that  he  was  at  the  moment  men- 
tally confused  and  had  acted  in  obedience  to  an  irresistible  impulse  born 
of  an  unfortunate  passion  he  had  for  women's  hair.  He  confessed  that 
he  had  cut  off  hair  many  times  before.  He  took  great  delight  in  keep- 
ing his  booty  at  home.  On  exanunation  of  his  ai)artments  sixty-five 
switches  and  locks  of  liair  were  found  assorted  in  [)ackets.  It  Avas  ascer- 
tained that  he  had  been  arrested  on  a  similar  charge  three  years  before, 

*  Op.  cit.,  p.  1G3. 


568  ^   .■<YSI£M   OF  LEGAL  MEDICLXE. 

T3Tit  had  been  dismissed  for  lack  of  e^-idence.  He  was  aged  forty ;  liis 
fatlier  liad  been  temporarily  insane  and  Ms  mother  was  very  nervous. 
P.  developed  well  and  was  intelligent,  but  he  early  exhibited  tics  and 
imperative  ideas.  He  had  never  practiced  onanism.  His  sexual  in- 
clination had  been  rather  Platonic ;  he  had  had  sexual  relations  with 
prostitutes,  but  very  infrec[iiently,  and  had  never  experienced  any  real 
plea.sui"e  in  coitus.  Three  years  jjre^-iously  financial  iniin  had  come,  and 
this  was  followed  by  a  febrile  disease  attended  with  dehrium.  Since 
that  time  he  had  been  subject  to  anxiety  when  alone  in  his  room  at 
night,  and  at  such  times  he  felt  an  impulse  to  fondle  female  hah'. 
When  he  could  touch  a  gu-l's  hair  he  became  gi-eatly  excited  sexu- 
ally, and  had  erection  and  ejaculation  without  other  contact  with  her 
person.  This  pleasure  gi-ew  to  be  more  and  more  intense,  and  pre- 
A"ions  sexual  intercourse  had  never  given  him  any  such  pleasui-e.  At 
last  he  could  not  resist  the  impulse  to  cut  off  a  gul's  hair  and  take  it 
home  to  fondle.  Here  he  repeated  the  process  of  inducing  sexual  or- 
gasm :  he  rubbed  his  person  with  the  hair,  etc.  After  this  he  could  not 
trust  himself  to  venture  out  for  several  days.  After  some  months  lie 
was  again  unable  to  resist  a  new  imi^uLse  to  repeat  his  experience. 
Driven  by  this  impulse  he  went  out  to  possess  himself  of  some  gui's  hair. 
This  was  fi-equently  repeated  imtiL  he  had  a  collection  of  packets  of  hair. 
If  he  were  unsuccessful  in  an  attempt  to  get  a  new  lot  of  hau-,  he  would 
huiTy  home  and  revel  in  his  possessions  there.  He  was  accustomed  to 
comb  and  fondle  it  and  siniidtaneously  j^ractice  mastui-bation.  Hah-  ex- 
posed for  sale  had  no  effect  on  Inm  ;  he  was  excited  only  by  that  hanging 
from  a  woman's  head.  When  he  touched  the  hair  with  the  scissors  it 
induced  erection,  and  ejaculation  took  place  at  the  instant  of  cutting  it. 
The  opinion  of  the  medico-legal  examiners  (Voisin,  Socquet,  Motet)  was 
to  the  effect  that  P.  was  a  psychoi^athic  person  subject  to  imperative 
impnLses,  of  which  his  impulse  to  steal  haii'  was  one  accompanied  with  a 
simidtaneous  excitation  of  sexiial  feeling  of  abnormal  character  and  in- 
tensity.    He  was  sent  to  an  asylum. 

A  similar  case  is  reported  by  Magnan.*  iu  which  it  was  possible  to 
trace  the  origin  of  the  impidse  to  association  of  the  sight  of  a  woman 
combing  her  hau'  with  a  primary  experience  of  spontaneous  sexual  ex- 
citement. 

When  some  particular  part  of  the  female  person  is  the  object  of 
erotic  interest,  the  fetichist  may  be  driven  to  illegal  measiu-es  to  satisfy 
his  desh-e.  Thiis  the  rounded  hips  of  a  woman  possess  such  attraction 
for  some  men  that  they  seek  to  place  themselves  in  contact  with  women 
secretly  iu  crowds.  Such  indecent  acts  have  fi-equently  been  the  subject 
of  legal  investigation. 

Dress=fetichism. — By  a  kind  of  psychological  substitution,  or 
thi'ough  pathological  association,  material  objects  may  come  to  be  the 
erogenous  fetiches.  The  process  of  substitution  is  for  the  most  part 
effectual  with  articles  of  female  wearing-apparel :  from  enthusiasm  for  a 
part  of  the  female  person  the  corresponding  customary  covering  may 
become  the  cause  of  erotic  excitement.  Thus  the  hand-fetichist  might 
develop  a  love  of  female  gloves :  or  the  foot-f etichist,  of  female  shoes. 
Often  the  fetich  is  some  particular  costume  or  some  special  article  of 

*  Fsychopathia  Sezualis,  p.  165. 


SEXUAL   CHIMES.  5G1) 

attire.  In  these  cases,  as  well  as  frequently  in  those  where  a  possiliilily 
of  transference  of  original  sexual  interest  in  parts  of  the  female  person 
is  sugg-ested,  psychological  association  of  primary  sexual  excitement  with 
the  particular  object  is  the  only  possible  explanation  of  the  origin  of  the 
pathological  manifestation.  The  more  the  ol)ject  of  erotic  ex(dtement  is 
foreign  to  the  normal  sexual  stimulus  the  more  serious  is  its  pathological 
signillcance. 

The  limits  of  this  article  will  not  permit  details  of  illustrative  cases. 
The  article^  most  likel^yto  become  the  ol)jeets  of  exclusive  ei-otic  interest 
are  shoes,  gloves,  petticoats  and  other  female  uuder-garments,  and  hand- 
kerchiefs. The  possibilities  of  pathological  association  are  such  that  any 
object  of  female  dress  may  eventually  become  a  fetich.  When  such  ob- 
jects are  erotic  fetiches  they  may  lead  the  individuals  to  commit  theft  to 
obtain  them.  The  following  case,  reported  by  Zippe,*  illustrates  this 
tendenc}' : 

X,  aged  thirty-two,  was  arrested  for  stealing  a  handkerchief  from  a 
lady.  He  confessed  that  he  had  stolen  a  great  number,  but  that  it  was 
not  for  gain  that  he  took  them.  He  cared  only  for  handkerchiefs  be- 
longing to  ladies  that  attracted  him.  He  showed  marked  mental  weak- 
ness. The  act  of  stealing  the  handkerchief  was  accompanied  by  true 
sexual  satisfaction,  and  this  gave  him  more  pleasure  than  normal  sexual 
congress.     He  looked  upon  this  theft  as  an  equivalent  for  coitus. 

The  following  case  b}^  Lombroso,  cited  by  von  Kraift-Ebing,t  is  an 
example  of  shoe-fetichism  combined  with  passivism  and  sadism:  X, 
male,  aged  twenty-six.  He  is  sexually  excited  by  nothing  but  the  shoes 
of  the  opposite  sex.  The  shoes  must  be  handsome,  of  black  leather,  and 
have  high  heels.  The  shoes  alone  suffice.  This  peculiarity  had  existed 
from  childhood.  X  is  potent,  but  the  female  diuiug  the  act  must  have 
on  dainty  shoes.  At  the  height  of  sensual  excitement  he  has  cruel 
thoughts  connected  with  the  shoes :  he  thinks  of  the  death-agony  of  the 
animal  from  which  the  leather  came.  At  times  he  takes  aninuils  (chick- 
ens) to  have  his  consort  tread  on  them  with  her  shoes ;  at  other  times  he 
has  the  woman  wallv  on  him  with  the  shoes.  Caressing  of  women's  shoes 
caused  erection  and  ejaculation.  Erotic  fetiehism  may  have  for  its  ob- 
ject some  special  material  such  as  fur  and  velvet.  The  cases  of  this 
character  are  usually  examples  of  association  independently  of  the  rela- 
tion of  the  special  material  to  the  opposite  sex.  In  such  cases  there  is 
experience  of  pi-imary  sexual  excitement  when  handling  velvet,  for  ex- 
ample, and  thereafter  this  association  is  maintained.  A  partiality  for 
furs  might  arise  from  experience  of  sexual  excitement  when  fondling 
furry  animals. 

Contrary  Sexuality  or  Sexual  Inversion. — The  cases  of  sexual  per- 
version falling  under  this  head,  as  previously  indicated,  are  divided  by 
von  Krafft  Ebing  into  two  classes,  namely,  acquired  and  co>uicnit(d.  We 
liave  seen,  however,  that  such  a  division  is  more  or  less  difficult,  if  not 
impossible,  and  that  a  more  practical  and  less  prejudicial  means  of  clas- 
sification is  to  separate  them  into  7(/;'?  (acquired)  and  earhj  (congenital) 
cases,  in  accordance  with  the  period  of  the  lii'st  manifestation  of  the  in- 
version. 

*  Wiener  Med.  JVochoiscJu-ift,  1879,  No.  23;  Psiichopatlua  ScruaUs,  p.  172. 
t  Oj>.  clt.,  p.  131. 


570  ^   STSTEAl  OF  LEGAL  MEDICINE. 

All  observers  agi'ee  in  the  conclusion  tliat  a  neui'opatMc  nervons 
system,  congenital  or  acqnii'ed,  is  a  prerequisite  for  the  development  of 
sexual  instinct  for  the  same  sex  (homosexuality).  To  this  predisposing 
neuropathic  condition  some  exciting  cause  is  added.  The  most  impor- 
tant exciting  or  contributing  causes  are  excessive  masturbation,  feai-  of 
pregnancy,  and  venereal  infection.  According  to  von  Ki-afft-Ebing,  the 
signs  of  a  nem-opathic  constitution  which  may  lead  to  sexual  inversion 
are  prematm-e  development  of  sexual  desii-e ;  sexual  hyperesthesia ;  func- 
tional and  anatomical  signs  of  degeneration ;  neui'oses  (hysteria  nem-as- 
thenia,  epileptoid  symptoms) ;  psychical  anomalies  even  to  degrees  of 
weak-mindedness  and  moral  insanity;  neui'oses  and  psj^choses  in  pro- 
genitors. The  same  author  differentiates  foni'  degrees  in  the  develop- 
ment of  the  inversion,  applicable  alike  to  early  and  late  cases :  1.  With 
predominating  homosexual  feeling  there  is  a, trace  of  feeling  (heterosex- 
ual) for  the  opjDosite  sex  (psychosexual  hermaphroditism) ;  2.  Exclusive 
homosexuality  limited  to  the  vita  sexualis;  3.  The  whole  character 
corresponds  with  the  incongruous  sexual  feeling;  4.  The  form  of  the 
body,  aside  from  the  genitals,  corresponds  with  the  anomalous  sexual 
inclination. 

Since  in  any  case  sexual  inversion  is  but  a  phenomenon  arising  from 
a  neui'opsychopathic  condition,  as  pre^dousty  indicated,  it  is  seldom  an 
isolated  manifestation,  but  is  most  frequent^  observed  in  combination 
with  other  sexual  perversions.  In  accordance  with  this,  the  medico- 
legal questions  arising  in  sexual  inversion  may  be  identical  ydWi  those 
raised  in  the  sexual  perversions  previously  considered.  The  further  pos- 
sibilities of  a  criminal  character  are  related  to  the  crimes  of  jiederasty. 
The  indi\ddual  affected  with  contrary  sexuahty  satisfies  himself  with  men 
by  means  of  passive  or  mutual  onanism,  or  by  coitus-like  acts  {coitus 
inter  femora) ;  if  active  pederasty  is  performed,  it  is  only  as  a  result  of 
intense  sexual  desire,  or  out  of  msh  to  please  another.  Passive  peder- 
asty may  be  performed  by  contrary  sexual  individuals  to  please  the  act- 
ive party,  or  out  of  lust  where  they  feel  themselves  entu-ely  in  the  femi- 
nine role.  To  distinguish  such  cases  from  pederasty  not  dependent  upon 
a  pathological  condition,  it  is  but  necessary  to  exclude  the  existence  of 
psychosexual  inversion,  and  to  remember  that  where  this  crime  is  per- 
formed apart  from  perversion  it  is  as  a  means  of  sexual  indulgence  in 
the  absence  of  oj)portunity  for  natm-al  satisfaction,  and  as  a  new  means 
of  sexual  gratification  where  natural  methods  of  sexual  pleasure  have 
been  exhausted  by  excess.  Non-pathological  passive  pederasty  is  prac- 
ticed onlv  for  gain. 

The  "follo^dng  uniiulilished  autobiography  will  illustrate  a  case  of 
sexual  inversion  of  early  development : 

"  From  my  earliest  childhood  I  have  exliibited  an  abnormal  sexual 
tendency.  I  have  never  loved  a  woman — never  experienced  a  trace  of 
sexual  feeling  for  a  woman.  Yet  I  cannot  say  that  I  have  a  Iwrror  femi- 
narnm.  I  do  not  associate  with  ladies,  not  because  I  dread  them,  but 
knowing  my  condition  I  feel  so  inexpressibh^  unhapp}^  by  reason  of  it 
that  I  avoid  their  society.  I  have  never  attempted  coitus  with  a  woman, 
because  I  have  no  desire,  and  then  again  I  know  it  would  be  impossibk-. 
Neither  do  I  consort  criminally  with  men.  My  desires  are  for  men  ex- 
clusively, but  they  have  never  yet  been  so  strong  that  I  was  unable  to 
control  my  actions.     Of  course  I  avoid  temptation.     In  all  my  thoughts 


SEXUAL   CRIMES.  571 

(s<'xually)  I  I'egai'd  myself  in  a  passive  role.  I  am  eff(,^minate  in  action 
and  appearance,  thon^li  I  am  told  I  am  less  so  than  f<n-merly.  My  voice 
is  a  good  ])aritone,  l)ea.rd  al)ui)dant,  heig'lit  five  feet  six  inches,  weight 
one  hnndred  and  seventy-two  pounds,  genitals  well  formed  (as  far  as  I 
can  judge),  but  somewhat  under  size,  and  as  far  as  I  know  they  are  in  a 
healthy  state.  I  do  not  practice  masturbation,  and  have  no  desire  to  do 
so.  I  did  practice  masturbation  for  many  years — probably  as  early  as 
my  tenth  year,  and  from  that  time  more  or  less  fre(|uently  until  I  left 
the  university  in  my  twenty-third  year.  I  do  not  think  I  ever  practiced 
it  oftener  than  once  in  f<nir  or  five  days.  Now,  however,  I  have  aban- 
doned the  habit  and  never  feel  any  inclination  to  renew  it.  Indeed  I 
never  think  of  it,  and  it  seems  incomprehensible  to  me  that  any  one 
should  care  to  indulge  in  it.  I  seldom  have  nocturnal  emissions — per- 
haps once  a  month — but  they  are  alway-s  accompanied  by  lascivious 
dreams  in  which  men  are  substituted  for  women.  I  am  inclined  to  be- 
lieve that  my  condition  is  congenital,  although  my  early  practice  of  mas- 
turl)ation  may  be  responsible  for  it.  I  always  as  a  child  was  fond  of 
dolls  and  sewing  and  other  feminine  things.  This  was  even  prior  to 
forming  the  hal)it  of  masturbation.  I  do  not  thiidv  either  of  my  parents 
had  any  almormal  sexual  feelings.  M}^  mother  died  when  I  was  thirteen 
years  old,  of  asthma — nervous  asthma,  I  think.  My  father  still  survives. 
My  father  never  seemed  to  me  to  care  for  ladies'  society.  I  never  knew 
him  to  visit  a  lady  unless  on  business,  and  his  reputation  for  morality  is 
of  the  highest.  Neither  does  he  ever  touch  liquor  or  even  smoke.  If 
lU}''  failing  is  inherited  it  must  be  from  my  father,  and  that  I  cannot  be- 
lieve. My  mother's  family  are  all  more  or  less  nervous,  but  are  consid- 
ered very  bright  mentall3^  Plowever  that  may  be,  I  have  this  abnormal 
tendency — or  rather  not  tendency',  but  appetite ;  for  it  is  more  than  a 
tendency — and  the  knowledge  that  I  am  so  unlike  others  makes  me  ver}" 
miserable.  I  form  no  acquaintances  outside  of  business,  keep  mostly  to 
myself,  and,  as  I  said  before,  do  not  indulge  my  sexual  feelings.  I  am 
at  times  exceedingly  melancholy,  owing,  I  suppose,  to  ray  unhappy  con- 
dition and  the  gr(3at  difference  between  myself  and  others.  Whenever  I 
go  into  society  this  difference  is  impressed  upon  me,  and  causes  me  such 
deep  distress  that  I  do  not  go  more  than  I  can  help.  I  do  not  w^ant  to 
create  the  impression  that  my  feelings  for  my  own  sex  are  weak,  for  they 
are  strong ;  but  I  have  heretofore  had  sufficient  wdll-power  to  restrain 
them.  On  one  occasion,  some  three  or  foiu-  years  ago,  I  permitted  a 
young  man  to  take  a  liberty  with  me,  at  his  request,  not  because  I  could 
not  resist  or  because  the  fcUow  had  any  attraction  for  me,  but  merely 
out  of  curiosity,  as  I  wanted  to  see  what  he  would  do.  I  took  no  Lib- 
erty with  him  and  merely  submitted  to  him  Avhile  he  put  my  penis  in 
OS  siiioii.  The  whole  thing  was  unpleasant  to  me  and  I  have  never  re- 
peated it.  I  have  already  stated  that  I  do  not  indulge  in  sexual  imjiro- 
prieties.  My  desire  in  this  matter  has  always  been  to  handle  the  genitals 
of  those  for  whom  I  feel  affection  and  to  have  them  do  the  same  to  me. 
I  am  therefore  somewhat  uncertain  as  to  whether  I  should  consider  my- 
self in  an  active  or  passive  role,  but  probably  passive.  This,  with  em- 
braces, seems  to  be  the  extent  of  my  desire.  But  the  most  serious  feature 
to  my  mind  is  the  total  and  utter  absence  of  any  feeling  for  w^omen.  I 
did  once  dream  of  having  connection  with  a  woman — not  a  woman  I  had 
ever  seen,  but  an  imaginary  creature — and  my  recollection  is  that  I  had 


572  ^   SYSTEM   OF  LEGAL  MEDICINE. 

an  emission  at  that  time.  Tliis  dream,  I  think,  was  caused  hy  my  firm 
resokition  made  about  that  time  to  try  to  concentrate  my  mind  on 
women  to  the  exclusion  of  men.  But  never  have  I  had  such  a  thought 
awake,  and  never  since  when  asleep." 

The  following  abridged  autobiography  illustrates  a  late  case  in  which 
there  are  distinct  evidences  of  psychosexual  hermaphroditism : 

"  I  am  twenty -nine,  and  born  of  healthy  parents.  My  sister  and  broth- 
ers are  normal.  As  far  back  as  I  can  remember  I  masturbated — long- 
before  I  reached  puberty.  I  practiced  mutual  mastiu'bation  with  but 
three  men,  all  older  than  myself — this  before  I  was  eighteen.  Since 
then  I  have  mastm'bated  alone.  I  practiced  self-abuse  very  frequently 
until  eighteen ;  from  that  time  until  my  twenty-fifth  year  about  once  a 
month ;  since  then  but  three  times  in  all.  I  have  frequent  pollutions  at 
night,  and  I  occasionally  awake  to  find  myself  masturbating.  With  these 
emissions  I  mostly  have  men  connected  in  my  dreams — occasionally, 
however,  women.  From  my  earliest  recollection  I  have  had  sexual 
thoughts  of  men  and  also  of  women.  From  fourteen  to  eighteen  I  had 
coitus  occasionally,  which  I  enjoj^ed,  but  not  so  much  as  the  pleasure  in 
onanism.  I  always  took  men  for  my  object  while  masturbating.  Men 
of  fine  figure  exert  a  great  sexual  effect  on  me.  I  have  never  yielded  to 
this  tendency.  My  attempts  at  coitus  for  some  years  have  been  very  un- 
satisfactory. I  fear  I  am  impotent  with  women,  but  I  have  no  trouble 
in  having  an  erection  at  the  thought  of  men.  There  are  times  when  this 
love  of  men  is  absolutely  obnoxious  to  me,  but,  alas !  they  are  only  too 
infrequent." 

Responsibility. — Since  all  forms  of  sexual  perversion  may  lead  to 
criminal  acts,  the  most  important  question  from  a  medico-legal  stand- 
point is  that  which  concerns  responsibility.  On  this  point  it  may  be  said 
that  the  fact  that  an  individual  is  subject  to  a  perversion  of  the  sexual 
instinct  is  not  sufficient  to  establish  personal  irresponsibility.  Many 
persons — in  fact,  the  majority — thus  affected  are  able  to  control  their 
abnormal  sexual  impulses.  When  such  a  person  has  committed  a  crime 
which  can  be  shown  to  be  the  expression  of  his  peculiar  anomaly,  in  or- 
der to  justify  a  judgment  of  irresponsibility  it  is  necessar}'-  to  show  that 
the  crime  was  the  result  of  organic  necessity ;  that  owing  to  a  nenropsy- 
chical  constitution  the  individual  was  incapable  of  developing  or  acquir- 
ing ideas  and  feelings  which  act  in  opposition  to  animal  impulses ;  or, 
these  having  been  developed  or  acquired,  that  pathological  conditions 
have  been  influential  in  overcoming  them.  Thus  the  question  of  re- 
sponsibility for  crimes  committed  by  sexual  perverts  falls  within  the 
lines  which  guide  in  the  determination  of  responsibility  in  general. 


SURaiCAL    MALPRACTICE. 

BY 

GEOEGE   EYEESOX  FOWLEE,  M.D. 


Definition. — Malpractice  is  defined  as  bad  or  unskillful  practice  on 
the  part  of  a  medical  attendant,  whereby  the  results  are  such  as  to  in- 
jure the  health  of  the  patient  or  destroy  his  life.  The  administration 
of  medicines  or  the  performance  of  an  operation  Avhich  the  practitioner 
knows  or  expects  will  result  in  damage  to  the  i)atient's  health,  needlessly 
endanger  his  life,  or  cause  his  death,  is  defined  as  willful  malpractice, 
while  negligent  malpractice  includes  those  instances  in  which  a  criminal 
or  dishonest  object  or  intention  is  absent,  but  in  which  there  is  gross 
negligence  or  failure  to  render  that  attention  to  the  patient  ^^■hich  the 
exigencies  of  his  illness  require.  The  administration  of  medicines  or 
the  performance  of  an  operation  if  the  medical  attendant  is  incapable  of 
properly  appreciating  its  effects,  either  in  regard  to  the  medicine  or  the 
operative  procedure,  tlirougli  any  fault  of  his  own — such  as  would  exist, 
for  instance,  when  he  was  in  a  state  of  intoxication — the  effect  being  to 
inflict  injury  rather  than  to  benefit  the  patient,  would  come  under  the 
latter  head.  Ignorant  malpractice,  on  the  other  hand,  consists  in  the 
administration  of  medicines  or  the  performance  of  operations  which  do 
liarm,  and  which  a  well-educated  and  scientific  medical  practitioner  would 
recognize  as  inappropriate  in  the  case  and  likely  to  be  followed  by  injuri- 
ous consequences. 

Tlie  passive  malpractice  iuvolved  in  allowing  a  patient  to  bleed  to 
■deatli  mthout  ascertaining  the  source  of  the  hemorrhage  or  taking  proper 
measures  to  arrest  it  is  quite  as  reprehensible,  caieris  parihux,  as  the  act- 
ive malpractice  involved  in  causing  a  dangerous  hemorrhage  for  want 
of  proper  care.  Errors  of  omission,  however,  are  of  as  great  importance 
as  those  of  commission,  yet  the  foi-mer  are  apt  to  be  judged  less  liarshly 
than  the  latter.  But  it  would  be  better,  viewing  the  matter  from  a  purely 
professional  and  scientific  standpoint,  to  reject  all  artificial  distinctions, 
and  consider  only  the  beliavior  of  the  sm'geon  ^nth  relation  to  the  nature 
of  the  disease,  the  condition  of  the  patient,  and  the  particular  prcx'edure 
•claimed  to  be  at  fault. 

Measure  of  Responsibility. — It  is  extremely  difficult  to  accurately 
■estiTnate  the  measure  of  the  surgeon's  responsibility  at  all  times  and 
under  all  circnmstances.  This  has  varied  greatly  in  times  past  and 
«imong  different  nations.  In  the  days  when  priests  assumed  the  func- 
tions of  medical  pT'actitioners  and  perf(n"med  surgical  operatiiuis,  their 
knowledge,  being  then  considered  as  derived  from  God,  was  looked  upon 

573 


574  ^   STSTE2I  OF  LEGAL  MEDICINE. 

as  infallible.  On  the  other  hand,  among  the  Egyptians  the  surgeon  who 
ventured  beyond  the  boundaries  of  the  rules  which  were  regarded  as 
established  was  liable  to  suffer  corporal  punishment,  even  though  his 
practice  was  successful.  In  Roumania  the  mere  fact  that  a  physician's 
or  a  sui'geon's  efforts  were  unsuccessful  made  him  responsible  at  law  for 
pecuniary  damages.  Among  the  western  Goths  the  unsuccessful  minis- 
trations of  the  siu'geon,  if  resulting  in  death,  were  followed  by  the  tui-n- 
ing  over  of  the  latter  to  the  vengeance  of  the  relatives  of  the  deceased 
patient.  In  Germany,  at  the  present  day,  both  the  Civil  and  Criminal  Code 
hold  to  a  strict  accountability  all  those  whose  office,  profession,  calling, 
or  trade  demands  the  exercise  of  care,  in  case  death  or  injury  results  f]*om 
the  want  of  proper  precautionary  measures.  In  England  there  are  no 
special  statutory  provisions  laid  down  defining  malpractice,  and  no  crimi- 
nal law  bearing  upon  the  subject  save  the  common  law.  All  cases  of  this 
character  are  treated  in  processes  before  jarors.  The  latter  course  is  like- 
wise pursued  in  the  United  States,  as  regards  both  civil  and  criminal 
processes ;  but  in  this  country  there  is  a  statutory  ]3i'ovision  on  the  sub- 
ject of  criminal  liability  for  negligence  or  misconduct.  In  Germany^ 
Austria,  and  France  the  trial  process  is  not  had  before  jurors. 

In  Germany  the  superior  courts  hold  to  the  princiiDle  that  every 
medical  practitioner  who,  by  a  culpable  want  of  attention  and  care,  or 
by  the  absence  of  a  competent  degree  of  skill  and  knowledge,  causes 
injuiy  to  a  patient  is  liable  to  a  civil  action  for  damages,  even  where 
the  patient  either  employed  him  or  agreed  to  paj'"  him,  unless  the 
patient  has  by  his  own  carelessness  directly  contributed  to  such  injur}-. 
A  siu'geon  does  not  stipulate  to  perform  a  cure,  neither  does  he  under- 
take to  use  the  highest  possible  degree  of  skiU,  but  he  does  undertake 
to  bring  a  fair  and  reasonably  competent  degree  of  skill  and  knowledge 
to  his  aid  in  the  case.  In  an  action  brought  to  recover  damages  the 
question  is  whether  the  injurj^  is  to  be  referred  to  the  want  of  a  proper 
degree  of  skill  and  care  on  the  part  of  the  defendant  or  not.  A  medical 
man  who  is  guilty  of  gross  negligence  or  evinces  a  gross  want  of  knowl- 
edge of  his  profession  is  criminally  responsible,  but  he  is  not  liable  to 
criminal  investigation  for  every  instance  in  which  an  unfortunate  termi- 
nation of  the  case  foUows  his  efforts.  The  distinction  between  actionable 
and  criminal  negligence  cannot  be  defined,  except  so  far  as  to  say  that 
to  constitute  the  latter  there  must  be  such  a  degree  of  complete  negh- 
gence  as  the  law  means  by  the  word  "  felonious."  The  American  courts 
hold  similar  \dews,  except  that  the  resi3onsil)ility  of  physicians  and  sur- 
geons is  not  to  be  measm^ed  by  the  same  rules  that  apply  to  mechanics 
and  artisans. 

Malpractice,  therefore,  has  come  to  be  an  offense  punishable  by  fine 
and  imprisonment  as  well  as  financial  loss  to  the  defendant  from  actions 
brought  by  patients  or  their  legal  representatives.  Under  the  common 
law  the  latter  cannot  recover  in  case  of  death,  inasmuch  as  the  act  of 
malpractice  constitutes  a  tort,  unless  some  property  interest  is  involved. 

That  exact  justice  demands  that  physicians  and  surgeons  should  be 
held  responsible  for  their  actions  as  well  as  their  omissious,  both  morally 
and  legally,  should  untoward  results  follow  their  willful  acts  as  weU  as 
their  failure  to  act  promptly  under  circumstances  demanding  such  action 
and  the  intelligent  application  of  ordiuary  skill  and  care,  there  can 
scarcely  be  two  opinions.     But  the  fact  should  not  be  lost  sight  of  that 


SlUaiCAL  M J JA'Ii ACTIVE.  575 

members  of  the  profession  of  liealing  should  not  be  restricted  in  the  selec- 
tion of  what  may  seem  to  them  the  proper  procedure  in  a  j^iven  case,  lest 
the  development  and  progress  of  their  humane  science  be  unnecessarily 
restricted  or  repressed. 

To  the  fair  and  impartial  mind  it  is  easily  apparent  that,  until  medi- 
cine becomes  an  exact  science,  in  a  certain  pi'oportion  of  cases  failure 
must  follow  the  efforts  of  the  best-informed  men,  the  failure  being 
attributable  to  the  conditions  for  which  the  treatment  was  applied  as 
well  as  to  errors  of  judgment  on  the  part  of  the  practitioner.  The  errors, 
however,  need  not  necessarily  be  cidpable  a  priori^  as  surgeons  are  but 
human,  and  are  liable  to  error  in  common  with  others  of  the  race. 

The  public  at  large  can  scarcely  be  justified  in  requiring  from  every 
individual  surgeon  the  highest  grade  of  knowledge  and  ability,  but, 
rather,  a  general  average  must  be  struck,  this  average  being  emplo^'ed 
with  whatever  especial  care,  X'l't'caution,  and  attention  are  required  l)y 
the  particular  case  in  hand.  Medical  knowledge  advances  by  stages,  and 
besides  the  improvements  which  each  decade  brings  to  the  profession, 
one  individual  member  thereby,  either  because  of  especial  opportunities 
for  observation,  the  possession  of  a  gift  of  genius,  or  as  the  result  of  an 
exceptionally  large  experience  in  a  particular  field  of  work,  may  outstrip 
his  fellows  and  attain  a  degree  of  proficiency  which,  if  estal)lished  as  a 
standard,  it  would  be  impossible  for  the  majority  of  his  professional 
l)rethren  to  reach. 

The  Principles  of  the  Art  of  Surgery. — The  general  truths  and 
maxims  which  authority  has  established  constitute  the  principles  of  an 
art ;  but  these  can  never  become  pei'manently  fixed  in  the  art  of  surgery, 
with  its  constant  advance  in  methods  and  scientific  improvements.  Un- 
til the  changes,  therefore,  wdiich  necessarily  follow  upon  the  latter  i-eceive 
the  sanction  of  recognized  authority  they  cannot  attain  the  weight  and 
importance  of  princij^les,  and  hence  changes  in  established  principles 
occur  but  very  slowly.  A  sufficient  knowledge  of  the  principles  upon 
which  the  practice  of  the  art  of  surgery  is  grounded,  and  an  intelligent 
application  of  those  principles,  therefore,  becomes  the  standard  hy  means 
of  which  a  judicial  estinuite  of  the  responsibilities  and  obligations  of 
the  surgical  practitioner  may  be  arrived  at. 

Opinions  of  Experts. — In  an  art  like  that  of  the  operative  portion  of 
sm'gery,  the  principles  of  which  are  undergoing  constant  improvements, 
and  which  are  susceptible  of  still  fui'ther  improvements,  in  order  to  de- 
termine the  civil  obligations  of  the  surgeon,  and  form  a  judicial  estimate 
as  to  how  far  he  has  availed  himself  of  trustworthy  kiuiwledge  upon  the 
subject  and  diligently  and  intelligently  applied  the  same,  it  is  necessary 
to  obtain  the  opinions  of  the  acknowledged  exponents  of  the  science  and 
art  whose  practice  and  experience  extend  over  the  particular  period  of 
time  under  review. 

Unexpected  and  Unfortunate  Results  of  Operations. — Although  the 
operating  surgeon  may  perform  the  most  difficult  and  extensive  opera- 
tions many  times  and  with  quite  a  uniform  degree  of  success,  and  those  of 
considerably  less  magnitude  will  occasioiuilly  be  followed  by  unfortu- 
nate and  unexpected  i-esults  from  causes  not  easily  foreseen  or  guardtnl 
against,  it  is  nevertheless  true  that  the  results  of  operations  generally 
depend  upon  the  qualifications  of  the  operator.  From  the  judicial  stand- 
point, therefore,  the  surgeon  who  undertakes  to  perform  an  operation 


o/( 


A   .'il'STEM  OF  LEGAL  MEDICISE. 


assoines  an  ol3ligation  wMcli,  thoiigli  onlj-  implied,  lias  all  tlie  force  of 
a  formal  conti'act  di-awn  and  signed  in  the  jjresence  of  "Ritnesses.  And 
fuither,  tMs  legal  construction  of  the  obligation  requu-es  that  the  sur- 
geon shall  possess  ordinaiy  skill  and  that  degi'ee  of  knowledge  which  is 
the  common  property  of  those  who  practice  the  same  art  and  science, 
intelligently  apply  those  2:)i"inciples  which  ai*e  deemed  essential,  under 
the  circumstances,  hy  the  leaders  of  the  profession,  and  for  the  best 
interests  of  the  patient,  and  employ  a  reasonable  degiee  of  care  and 
judgment  in  the  exercise  of  his  skill  and  in  the  application  of  the  prin- 
ciples to  which  allusion  has  been  made* 

The  Criteria  of  Malpractice. — Speaking  in  a  general  way,  it  may  be 
stated  that  the  three  criteria  of  malx)ractice,  and  upon  the  estabhshment 
of  which  actions  at  law  must  dei)end  in  order  to  be  successful,  are  em- 
braced in  the  following  questions :  Fii'st,  Has  injury  been  inflicted  or  has 
death  been  caused  by  the  act  of  the  siu'geon  ?  Second,  Did  the  attendant 
in  his  treatment  of  the  case  exhibit  a  want  of  knowledge  of  those  rules 
which  ai-e  the  common  property  of  the  profession,  or  which  have  been 
sufficiently  long  established  to  become  known  to  him  with  ordinary  watch- 
fulness of  the  advances  of  his  art  on  his  part  ?  Thii-d,  Did  the  attend- 
ant depart  from  the  estabhshed  rules  bearing  upon  the  particular  case  in 
an  unjustifiable  or  extraordinary  degi'ee  ?  In  other  words,  did  he  omit, 
either  through  carelessness  or  ignorance,  to  do  that  which  might  have 
been  of  benefit  or  have  saved  the  life  of  the  patient ;  or  did  he  adminis- 
ter a  remedy  or  perfoiTa  an  operation  which  resulted  in  injiuw  or  death, 
without  sufficient  reason  for  so  doing,  fi'oni  the  scientific  standpoint  as 
judged  by  Ms  peers  in  the  profession  ? 

Errors  in  Diagnosis. — The  iDarticular  dii'ection  which  the  error  com- 
mitted takes  should  also  have  some  bearing  upon  the  case.  For  instance, 
a  diagnostic  eiTor  in  an  obscm-e  case,  the  ti-eatment  being  properly  based 
upon  such  error,  should  be  deemed  less  culpable  than  either  wi-ong  or 
correct  diagnosis  followed  by  treatment  calculated  to  be  of  no  service 
or  absolutely  hannf  iil  in  either  case. 

Diagnostic  mistakes  have  been  made  by  the  most  eminent  i3ractition- 
ers  and  consultants,  and  upon  his  ability  as  a  diag-nostician  the  entire 
reiiutation  of  a  surgeon  frequently  depends.  An  error  in  diagnosis, 
therefore,  should  be  \-iewed  in  a  more  charitable  light  l^y  his  confreres, 
and  also  by  the  community,  than  errors  in  treatment  which  caused  dis- 
aster. This  is  fortunate  for  the  practitioner,  for  the  reason  that  when  a 
correct  recognition  of  the  case  on  his  part  has  been  j)roved  it  is  difficult 
to  x>roA'e  that  a  wi-ong  treatment  has  been  piu-sued ;  and  from  the  f lu'ther 
fact  that  the  diagnosis  in  a  large  number  of  instances  can  only  be  cleared 
up  by  observing  the  results  of  treatment.  Under  these  cii'cumstances, 
therefore,  the  treatment  must  be  largely  experimental  and  consequently 
more  or  less  at  variance  with  any  set  of  hard  and  fast  rules  which  might 
be  urged  as  applicable  to  the  case. 

Errors  of  Judgment. — Wliile  the  surgeon  is  bound  to  give  his  patients 
the  benefit  of  his  best  judgment,  he  is  not  lial:)le  for  a  mere  error  of  judg- 
ment, unless  it  can  be  shown  that  the  latter  is  so  gross  as  to  be  incon- 
sistent with  reasonable  care,  skill,  and  diligence,  t 

*  14  Am.  &  Eng.  Encvel.  of  La-n-.  76. 

t  Westxs.  Martin,  31  Mo.  375;  Howard  vs.  Grover,  28  Me.  97. 


SURGICAL  MALPRACTICE.  577 

Unusual  and  Extraordinary  Emergencies  and  Surroundings. — Tlie 
surgeon  is  compelled  oeca.sioiiully  to  act  under  circuinstances  of  the  most 
trying  and  extraordinary  character.  .His  own  safety  may  be  imperiled 
at  the  very  moment  he  is  called  upon  to  act  in  ])ehalf  of  another.  The 
surroundings  upon  a  hattle-field  or  a  railroad  wreck  are  not  conducive  to 
an  even  balance  of  mind,  or  calculated  to  assist  in  ])ringing  a  cool  and 
calm  judgment  of  the  necessities  of  the  case  to  the  aid  of  the  attendant. 
Local,  t(!mporal,  and  external  conditions  of  various  kinds,  as  well  as  the 
necessity  for  acting  at  once;  the  exigencies  of  a  case  demanding  prompt 
action,  and  that  perhaps  with  material  of  a  hastily  imj)rovised  character 
and  ill-adapted  to  the  emergency,  may  prevent  the  surgeon  from  making 
use  of  knowledge  which  he  really  possesses,  or  from  showing  that  ahility 
which  under  nu)re  favorable  circumstances  he  would  exlnhit.  Moreover, 
the  necessity  at  times  for  the  rapid  performance  of  an  operation,  as,  for 
instance,  tracheotomy,  or  the  prompt  application  of  a  remed}^  in  an 
emergency,  may  be  al)solutely  incompatible  with  the  exercise  of  due 
care  and  precaution  against  accident.  In  addition,  the  importunities  or 
expostulations  of  the  patient  or  his  friends  may  serve  to  bias,  or  at  all 
events  to  disturb,  the  judgment  of  the  surgeon  and  tend  to  lead  him  into 
error. 

Latest  Methods  and  Appliances. — Where  the  exigencies  of  the  case 
will  permit,  and  where  there  exist  no  extenuating  circumstances  such 
as  have  been  already  dwelt  upon,  the  surgeon,  in  the  perfornjance  of  all 
surgical  operations,  is  bouiul  to  bring  at  least  the  ordinary  care  and 
skill  possessed  hy  those  who  practice  in  the  same  locality  or  have  access 
to  the  same  sources  of  information  which  he  can  avail  himself  of.*  He 
must  possess  and  exercise  in  an  intelligent  and  practical  manner  that 
degree  and  amount  of  knowledge  and  science  which  the  best  authorities 
have  declared  to  be  the  result  of  their  observation,  experience,  or  re- 
search, up  to  within  a  reasonable  time  of  the  date  of  the  error  of  com- 
mission or  omission  which  is  at  issue. t 

Response  to  a  Call  and  Duration  of  Attendance. — Reproach  is  some- 
times cast  upon  the  surgeon  for  failiu'e  to  respond  to  a  call  for  profes- 
sional services  in  urgent  cases.  It  is  his  implied  duty,  if  he  is  the 
regular  attendant,  to  properly  attend  the  case  so  long  as  it  requires 
attention,  unless  his  services  should  be  no  longer  acceptable  to  the  patient, 
in  which  case  a  formal  dismissal  will  be  in  order.  He  may  Likewise  vol- 
untarily cease  his  attendance  upon  the  case  at  any  time  upon  giving  rea- 
sonable notice  of  his  intention  to  do  so,  if  further  care  is  necessary.  It 
is  also  within  his  province  to  determine  when  attendance  may  be  safely 
and  properly  discontinued,  but  the  same  rule  in  regard  to  the  exercise  of 
ordinary  care  and  skill  likewise  holds  good  in  this  connection.  Special 
contracts  may  be  made,  however,  between  the  surgeon  and  the  patient, 
limiting  the  attendance  to  a  longer  or  shorter  period,  or  to  a  single  visit, 
or  governing  the  frequency  of  the  visits.f 

*  Grnnini  vs.  Bonier,  56  Ind.  497;  Kchci/  vs.  Hai/,  84  Ind.  189. 

t  Elwell  on  Mal]irac1i(T ;  Am.  Law  Eeg.  (N.  S.)  774;  8  East  (Eug.),  347;  1  H.  Bl. 
(Eng.)  61  ;  MrCaiidlrss  vs.  McWIm,  22  Pa.  St.  261;  27  N.  H.  460;  13  B.  Mon.  219; 
Shearman  &  Redfiold,  vS  440;  McLaJoii  vs.  Adanis,  19  Pick.  (Mass.)  333;  Cnrpeuter 
vs.  Blake,  60  Barb.  448  ;  'Patleu  vs.  Wiqqhi,  51  Me.  594;  Rex  vs.  Long,  4  C.  &  P.  (Eug.) 
423;  Shilvv  vs.  Bokvr,  2  Willes  (Eng.'),'  2.j9. 

X  See  Ballon  vs.  rrcacott,  64  Me.  305;  Todd  vs.  Meyers,  40  Cal.  357. 


578  ^  SYSTEM  OF  LEGAL  MEDICINE. 

No  Implied  Warranty  to  Cure — Express  Stipulation. — The  mere 
■employment  of  a  sm-geon  does  not,  in  the  legal  sense,  imply  a  contract 
to  cure,*  although  the  surgeon  may,  at  his  discretion,  contract  to  per- 
form a  ■  cure  absolutely,  in  which  case  he  can  be  held  as  a  guarantor 
of  success.t  The  profession,  however,  has  always  looked  upon  such 
bargains  with  disfavor.  The  surgeon,  when  he  enters  upon  the  charge 
of  a  case  with  dignity  and  a  due  regard  for  his  professional  standing, 
is  not  in  any  sense  supposed  to  insure  a  cure,  and  hence  is  not  to  be 
tried  for  the  result  of  his  efforts,  pro\dding  he  treats  the  case  with  rea- 
sonable diligence,  care,  and  skill.  More  than  this  may  be  expected  and 
demanded  if  an  express  stipulation  exists,  precisely  as  in  common  con- 
tracts between  individuals  in  commercial  life.  The  mere  fact  that  the 
surgeon  attends  for  a  fee  simply  implies  that  he  shall  exercise  care,  dili- 
gence, and  skill  in  all  his  acts,  and  that  these  shall  be  such  as  are  best 
calculated  to  restore  the  patient  to  health,  and  least  likely  to  injuriously 
affect  him. 

Equal  Amount  of  Time  and  Attention. — The  surgeon  is  not  always 
bound  to  bestow  an  equal  amount  of  time  or  degree  of  attention  and 
skill  upon  all  who  come  under  his  care,  much  less  is  it  necessary  that  he 
should  carry  these  to  the  same  extent  as  some  other  medical  man  might 
have  done.  In  order  to  render  him  hable  it  must  be  shown  that  damage 
has  been  inflicted  and  that  there  has  been  a  want  of  competent  and  ordi- 
nary care  or  skill,  or  an  indifference  to  the  patient's  best  interests.  Even 
an  admission  on  the  part  of  the  sui-geon  himself  that  there  has  been  a 
lack  of  care  on  his  part  does  not  alter  the  case  so  far  as  is  concerned 
the  necessity  of  proving  that  there  was  such  lack  of  care,  and  that  the 
patient  suffered  in  consequence  thereof. 

The  i)roposition  that  the  surgeon  is  not  bound  to  give  the  same  or 
equal  care  and  attention  to  all  cases  is  based  upon  the  fact  that  each 
case  is  to  be  individualized,  and  that  the  peculiar  mental  qualities  of  one 
patient,  although  not  very  ill,  will  demand  more  attention  tlian  required 
by  another  who  is  more  seriously  ill,  yet  not  so  profouudly  impressed 
mentally  as  to  require  oft-repeated  assurances  of  continued  well-being. 
So  many  factors  may  enter  into  the  consideration  of  the  case  in  this  con- 
nection that  it  would  be  absurd  to  permit  a  standard  to  be  set  up  based 
upon  the  patient's  own  ijreferences.  It  is  not  sufficient  that  the  patient 
asserts  that  he  did  not  get  as  much  care  as  he  desired :  he  must  show 
that  he  was  damaged  by  insufficient  care  or  inefficient  treatment,  and 
that  these  were  avoidable  on  the  part  of  the  attendant. 

Gratuitous  Services. — Tlie  fact  that  a  surgeon  renders  services  gra- 
tuitously does  not  affect  his  duty  to  exercise  reasonable  and  ordinary 
care,  skill,  and  diligence.f  Treating  a  patient  gratuitously  does  not  give 
the  surgeon  license  to  treat  him  other  than  in  a  scientific  and  careful 
manner  and  with  due  regard  to  his  best  interests.  In  fact,  failure  on 
the  part  of  a  surgeon  to  render  a  bill  or  make  some  claim  for  compeiisa- 

*  Teft  vs.  Wilcox,  G  Kan.  446 ;  Heese  vs.  Knippel,  1  Mich.  N.  P.  109 ;  Getchel  vs. 
HUl,  2l"Minu.  464  ;  O'Hara  vs.  Jrellft,  14  Neb.  403  ;  Leif/hfoii  vs.  Sargent,  27  N.  H.  460  ; 
CraiffYH.  Clianiherf:,  17  Ohio  St.  253;  J3/w.s'  vs.  Lmiq,  Wright  (Ohio),  351;  Grvidle  vs. 
Bud,  7  Ohio,  pi.  2,  123. 

t  Eh/  vs.  inibnr,  49  N.  J.  L.  685;  Gallahcr  vs.  Thompson,  Wright  (Ohio),  466;  Sniiih 
vs.  Hijdc,  19  Vt.  54. 

X  McXcrhis  vs.  Lowe,  40  IlL  209. 


tiilUllCAL  MALl'liACTIVE.  579 

tion  for  the  treatment  of  a  case,  and  the  inability  on  his  part  to  explain 
tliis  otlierwise  than  np<^)n  the  g-roiind  tluit  the  patient  was  a  liospital  or 
dispensary  patient  east'  wliich  came  under  his  care  as  such,  ini<!,ht,  in  an 
action  for  inali)ra(*ti('e,  and  especially  in  a  doubtful  or  l)alanced  case,  he 
nr^ed  with  great  force  as  in  the  nature  of  an  admission  of  neglect  oi- 
want  of  skill  on  tlie  part  of  the  surgeon — as  evidence  of  a  consciousness 
that  he  was  not  entitled  to  pay  for  his  services,  and  that  the  latter  were 
wortldcss.* 

Experience  and  Instruction  Will  Vary. — The  law  does  not  demand 
the  most  thorough  education  or  the  most  extensive  experience  on  the 
part  of  the  surgeon — evidently  it  cannot,  because  experience  and  instruc- 
tion will  vairy — l)nt  it  will  not  countenance  qna(;kery.  An  uneducated 
or  ignorant  pei'son  who  attempts,  under  pretense  of  l)eing  a  qualified 
medical  practitioner,  to  jjcrform  surgical  operations  is  to  be  held  account- 
able, both  criminjdly  and  civill}',  for  the  results  of  his  actions.  If,  how- 
ever, there  is  an  nnderstanding  between  the  patient  and  the  surgeon, 
who  frankly  confesses  his  want  of  skill,  or  even  if  the  patient  is  made 
fully  awai'e  in  some  other  way  of  the  lack  of  knowledge  and  ability  on 
the  part  of  the  practitioner,  he  cannot  complain  of  the  bad  result,  since 
this  depends  upon  the  lack  of  those  qualities  which  he  was  informed  did 
not  exist.t 

Effects  of  Locality  upon  Standard  of  Care  and  Skill. — The  stand- 
ard of  skill  may  not  only  vary  under  the  vaiyiug  circumstances  already 
mentioned,  but  it  may  differ  in  different  portions  of  the  same  country 
or  even  State.  Thus,  for  instance,  medical  practitioners  in  rural  districts, 
or  even  in  towns  of  considerable  size  remote  from  medical  centers,  al- 
though well  i-ead  and  grounded  in  the  theory  of  the  profession,  are  com- 
paratively seldom  called  iq)on  to  assume  charge  of  grave  surgical  con- 
ditions or  perform  difficidt  operations.  These  men  do  not  enjoy  the 
opportunities  which  the  more  fortunate  city  practitioner  does,  of  daily 
observation  and  more  or  less  of  constant  practice,  and  it  would  l)e  nmst 
unreasonable  to  demand  from  them  the  same  degree  of  skill  which  hos- 
pital practice  or  daily  work  in  a  larger  field,  witli  the  opportunities  foi- 
consultation  with  recognized  authorities  and  of  listening  to  or  participat- 
ing in  discussio]is  at  the  medical  societies  upon  subjects  in  which  those 
who  take  part  are  pai'ticularly  interested  and  have  therefore  studied 
with  particular  care,  would  imply. 

The  Surgeon  is  Bound  to  Use  the  Best  that  he  can  Command. — 
Peculiarities  of  environment  may  denuind  of  a  surgeon,  although  com- 
paratively unlearned,  unskillful,  or  inexperienced,  in  an  emei'gency,  or 
where  the  patient  cannot,  from  one  reason  or  another,  be  transported  to 
Sk  hospital  or  medical  center,  or  pay  a  skillful  surgeon  to  visit  him,  the 
rendering  of  such  services  as  he  may  l)e  able  to  give.  Under  such  circum- 
stances he  may  undertake  an  operation  which  he  has  never  seen  per- 
formed, or  the  application  of  apparatus  with  the  mechanism  or  rationale 

*  14  Am.  &  Ens.  Encycl.  of  Law,  81 ;  Baml  vs.  GiUettc,  47  N.  Y.  186. 

t  Sliearman  &  Redfteld  on  Xe(/Ii(/('ii<'e,  §^S  433-435;  Leigh  ton  vs.  S(irf/c))t,  27  Me. 
(7  Fost.)  4G8;  liciinohli  vs.  driircs',  3  Wis.  416;  Carpenter  vs.  BJal-e,  60  Barb.  (N..Y.) 
488 ;  Patten  vs.  Wiqqin,  51  Me.  594 ;  Brigqfi  vs.  TatfJor,  28  Vt.  180 ;  Landon  vs.  H>nn- 
phreij,  9  Coim.  209;  MeXcrin  vs.  L<m-e,'iQ  111.  209;  Smothers  vs.  HanLs,  34  la.  286; 
Teff  vs.  TViJeo.r,  6  Kan.  46 ;  Howard  vs.  Graver,  28  Me.  97 ;  Long  vs.  Morrison,  14  Ind. 
■595  ;  11  Am.  Hop.  363. 


580  -^   SYSTEM  OF  LEGAL  MEDICINE. 

of  whicli  he  is  imfamiliar  or  Tinaeqiiainted,  and  yet  be  perfectly  justified 
in  giving  snch  aid  as  lie  can.  All  that  the  law  requires  in  this  connec- 
tion is  that  he  shall  use  the  best  that  he  has  at  his  command,  whether 
of  knowledge  as  to  what  to  do,  skill  in  doing  it,  or  of  apparatus  or  in- 
struments. 

Experimental  Surgery. — The  question  of  experimental  surgery  as 
apphed  to  human  beings  is  one  of  much  importance.  The  law  is  rather 
expUcit  on  the  subject,  and  decisions  have  agi'eed  that  a  medical  man 
cannot  experiment  upon  his  patients  without  liabihty  to  damages,  sliould 
injury  or  death  follow,  and  be  due  to  such  experiment.*  It  would  be  a 
question  for  careful  consideration  on  the  part  of  a  jury  whether  or  not 
the  experiment,  under  the  circumstances,  was  a  justifiable  one.  For  in- 
stance, in  a  condition  which  would  ordinarily  be  easily  cured  by  simple 
means,  and  which,  if  uncm-ed,  would  not  give  rise  to  great  discomfort, 
disability,  or  danger,  it  would  follow  that  the  application  of  a  dangerous 
or  heretofore  untried  remedy  or  operation  which  left  the  patient  in  a 
worse  condition  than  before,  or  resulted  in  his  death,  would  be  followed 
by  severe  condemnation,  even  with  a  jur}^  of  medical  men.  On  the  other 
hand,  with  a  patient  suffering  from  an  incurable  and  necessarily  fatal 
malady,  and  in  whom  all  kno^^m  remedies  have  failed  to  bring  relief,  a 
much  wider  latitude  of  action  may  be  permitted  the  practitioner. 

Experimental  Treatment  not  Necessarily  Culpable. — Condemna- 
tion of  expernnental  treatment,  strictly  speaking  (for  all  treatment  is 
more  or  less  experimental  in  a  general  sense),  may  be  carried  so  far  as 
to  constitute  a  serious  bar  to  progress  in  medical  science.  An  experi- 
ment is  not  always  to  be  regarded  as  culpable  of  itself,  for  the  reason 
that  there  is  not,  nor  can  there  ever  be,  a  legal  code  containing  the  rules 
of  medical  science.  On  the  contrary,  the  thoughtful  and  scientific  phy- 
sician "v\dU  always  endeavor  to  indi\ddualize  each  case  in  its  treatment, 
and  proceed  in  accordance  with  the  dictates  of  his  own  judgment.  He 
is  therefore  often  justified  in  acting  in  opposition  to  established  rules. 
Progress  in  medical  science  depends  upon  independent  research  and  the 
free  selection  of  methods  of  procedure.  Therefore  not  even  an  untoward 
result  of  a  course  of  treatment  differing  from  that  which  is  ordinarily 
pursued  need  necessarily,  as  has  been  assumed,  be  construed  as  mal- 
practice. Even  good  results  do  not  always  protect  the  surgeon  against 
reproach. 

A  new  and,  therefore,  untried  procedure  may,  despite  the  fact  that 
the  patient  died  in  consequence  of  its  employment,  be  regarded  as  rea- 
sonable and  justifiable.  This  is  just  as  true  as  the  proposition  that  a 
standard  operative  procedure  in  which  all  the  rules  laid  down  by  author- 
ities are  followed  fi'e(|uently  fails  to  save  the  patient,  and  may  even  be 
dii-ectly  held  responsible  for  his  death.  If  the  surgeon  is  able  to  give 
such  reasons  for  his  course  as  are  satisfactory  to  scientific  men,  and  has 
employed  the  new  procedure  with  care  and  due  attention  to  all  of  the 
possibilities  in  the  case,  and  in  good  faith,  then  he  is  not  to  be  nmlcted 
in  damages  because  of  an  unfortunate  outcome  of  his  effort  to  improve 
upon  older,  and  probably  not  more  satisfactory,  methods. 

Improper  Introduction  of  Non=Professional  Persons  into  a  Case. — 
The  introduction  of  a  non-professional  person  into  a  case,  and  in  which 

*  ratten  vs.  Wiffffin,  51  Me.  594. 


SURUICAL   MALriLlCTlCE.  5{^1 

uo  necessity  exists  for  his  presence  or  assistance,  may  render  the  prai;- 
titioner  and  the  intruder  liable  for  whatever  damages  ixvdj  have  Ijecn 
sustained  by  the  patient.  In  the  recorded  instances  in  which  the  parties 
committing  the  offense  wen;  held  liable,  tlio  pati(?nts  were  women  in  con- 
finement. The  offense  was  not  milii^ated  nor  the  rij^'ht  to  recover  af- 
fected by  the  fact  that  both  the  patient  and  her  husband  supposed  the 
intruder  to  be  a  medical  man  and  tiierefore  made  no  objection  to  liis 
presence.*  The  fact  that  the  inti'uder  was  an  unmarried  as  well  as  a 
non-professional  man  seems  to  have  affected  the  cpiestion,  so  far  as  the 
cases  cited  are  concerned.  But  there  are  other  considerations  aside  from 
those  of  shame  and  modesty  which  would  serve  as  a  basis  for  a  suit  for 
damatres,  such,  for  instance,  as  those  relating  to  privileged  comnuinica- 
tions,  the  presence  of  venereal  eruptions  upon  tlie  skin,  etc. 

Burden  of  Proof  and  Matters  in  Defense. — As  to  the  burden  of 
pr(_)of,  this  follows  a  general  rule  with  which  attorneys  are  familial-,  and 
which  need  only  be  casuall}^  alluded  to  in  this  connection :  ''  As  to  the 
order  of  the  production  of  evidence,  it  is  held  that  the  biu-den  of  proving 
any  fact  lies  upon  the  pai'ty  who  substantially  assei'ts  ihe  affirmative  of 
the  issue."  t  Where  the  surgeon  is  put  upon  the  defensive  and  enters  a 
denial  of  the  claim  for  damages,  the  plaintiff  must  prove  in  an  affirma- 
tive manner  all  of  the  essential  and  material  elements  entering  into  the 
negligence  as  specifically  charged.  Not  only  this,  but  there  must  be  a 
preponderance  of  evidence,  not  only  in  these  respects,  but  particularly 
where  want  of  skill  or  knowledge  is  charged,  before  the  verdict  of  a  jury 
can  be  claimed  in  favor  of  the  plaintiff.  Most  especially  is  it  necessary 
for  the  plaintiff  to  establish  an  exact  etiological  relation  between  the 
result  of  the  alleged  malpractice  and  the  negligent,  careless,  or  willful 
maltreatment.  In  addition  to  this  it  falls  within  the  pro^dnce  of  the 
in(piiry  whether  there  are  not  causes  other  than  those  relating  to  the 
j)rocedure  complained  of  which  may  be  held  partly  or  wholly  responsible 
for  the  failure  of  the  treatment.  Furthermoi-e,  the  question  arises  as  to 
wdiether  or  not  the  methods  emplo^yed  and  alleged  to  be  faulty  have  been 
followed  by  successful  results  in  analogous  cases.  Finally,  the  justifia- 
bility of  the  procediire,  providing  it  be  a  new  one,  should  be  discussed 
upon  a  purely  scientific  basis,  the  question  as  to  the  propriety  of  its 
employment  depending  largely  upon  whether  or  not  its  rai'wnale  can  be 
explained  upon  scientific  principles,  or  appeals  to  the  uni^rejudiced  minds 
of  scientific  men. 

Contributory  Negligence. — It  is  a  well-defined  principle  of  law  that 
upon  each  person  devolves  the  duty  of  exercising  reasonal)le  care,  dili- 
gence, and  prudence  in  avoiding  personal  injuries  as  well  as  damages  or 
losses  resulting  from  the  wrongful  acts  of  others.  Persons  who  are  ill 
and  under  the  care  of  a  professional  attendant  can  no  more  escape  the 
responsibility  arising  from  faihn-e  to  observe  this  rule  than  he  who  walks 
the  street.  Hence  it  follows  that  if  there  is  sliown  any  want  of  ordinary 
and  proper  care  and  diligence  on  the  part  of  the  patient  to  avoid  the 
consequences  which  may  arise  from  malpractice,  he  may  be  chargeable 
with  contributory  negligence,  and  this  plea,  may  be  set  up  in  defense  of 
the  action  or  in  mitigation  of  the  damages  claimed.    The  plaintiff,  if  this 

*  Be  Mai/  vs.  Roberts,  4(5  Midi.  160;  41  Am.  Rop.  154. 
t  Field's  JIc(lico-Lc(/(il  Guide,  p.  218;  Field's  Briefs,  §  310. 


582  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

contributory  negligence  on  Ms  part  is  proved — and  the  burden  of  proof 
of  this  is  upon  the  defendant  * — ^vill  be  debarred  from  recovering,  or,  at 
the  most,  it  ^vill  be  found  that  he  can  recover  only  to  a  limited  extent. 
The  limit  to  be  placed  upon  the  amount  which  he  mil  be  able  to  recover 
will  be  governed  by  the  extent  to  which  it  was  in  his  power  to  prevent 
the  damage  inflicted,  by  the  exercise  of  ordinary  and  reasonable  care  and 
diligence,  t  Therefore,  while  a  siu'geon  is  hable  for  any  injury  caused 
the  patient  by  the  want  of  that  ordinary  skill  and  dihgence  which  an 
intelligent  and  reputable  member  of  the  profession  would  use  under  the 
same  circumstances,  and  which  the  laws  of  the  country  i'equii*e,  yet  if 
the  patient  neglects  or  refuses  to  make  use  of  the  remedies  prescribed, 
or  dechnes  to  permit  a  necessary  operation  to  be  performed,  it  goes 
without  saying  that  he  thereby  absolves  the  attending  surgeon  from  all 
responsibility  for  any  injurious  consequences  that  may  occiu*,  if  such 
neglect  or  refusal  can  be  shown  to  be  a  proximate  cause  of  the  injury ; 
even  though  the  surgeon  may  have  failed  to  employ  that  degree  of  ordi- 
nary skill  and  diligence  which  is  demanded  under  the  law,  still,  if  the 
patient  contributes  to  the  injiuy  by  any  f aihu'e  on  his  own  part  or  on 
that  of  his  attendants  to  property  cooperate  ^\\\h  the  medical  attendant, 
it  has  been  held  that  he  cannot  recover  damages  for  such  injury,  t 

The  proposition  last  stated  does  not  hold  good  in  mitigation  of  dam- 
ages where  one  person  has  received  a  personal  injiuy  from  negligence 
on  the  part  of  another ;  in  other  words,  the  ordinary  personal-damage 
smts  of  the  coui'ts  are  not  criteria  in  these  cases.  Under  these  ciix'um- 
stances  the  claim  for  damages  on  the  part  of  the  plaintiff  cannot  be  otfset 
or  the  amount  rediiced  by  reason  of  his  failure  to  secure  the  most  skillful 
professional  aid,  pro%'iding  he  has  iised  reasonable  and  ordinary  care.  § 

Elements  of  Pecuniary  Damages. — The  elements  of  the  pecuniary 
damages  which  may  be  sustained  in  any  given  case  have  been  classified 
as :  (1)  loss  of  time  and  labor  arising  from  the  injury  sustained  by  the 
malpractice :  (2)  the  reasonable  expenses  inciu-red  for  surgical,  medical, 
and  other  attendance ;  (3)  diminished  capacity  to  work  at  the  trade  or 
business  of  the  injured  party  in  consequence  thereof ;  (4)  bodily  pain 
and  mental  anguish  in  consequence  thereof.  In  addition  to  these  a  jury 
may  take  into  consideration  the  fact  of  permanent  disability  and  proba- 
ble future  disabihty  and  suffering,  the  principle  here  being  the  same  as 
that  which  is  applied  in  estimating  damages  for  personal  injmy.  ||  In 
fact,  when  the  elements  of  fraud,  msilice,  gross  neghgence,  or  oppression 
are  introduced  into  the  controversy  the  case  permits  the  jury  to  gi^^'e 
punitive,  ^dndictive,  or  exemplary  damages.  S\ 

The  j)laintiff  in  an  action  for  malpractice  is  not  entitled  to,  nor  should 
he  be  permitted  to  recover,  damages  on  account  of  the  pain  and  siiif  ering 

*  Gramm  vs.  Boener,  56  lud.  497.  A  contrary  rule  is  adopted  in  Iowa :  Baird  vs. 
Morford,  29  la.,  531. 

t  Field's  Laivyers'  Briefs,  ^  445,  446;  Field's  Mcdico-Ler/al  Guide,  p.  221. 

t  Geiselman  vs.  Scott,  25  Ohio  St.  86 ;  Loirer  vs.  Fniiiks,  115  Ind.  334 ;  Chamherlain 
vs.  Porter,  9  Minn.  260 ;  Hihbard  vs.  Thompson,  109  Mass.  286 ;  36  Am.  Rep.  668 ; 
Potter  vs.  Warner,  91  Pa.  St.  362 ;  West  vs.  Martin,  31  Mo.  375 ;  Jones  vs.  Angell,  95 
Ind.  376 ;  O'Hara  vs.  Wells,  14  Neb.  403. 

?.  32  la.  324 ;  7  Am.  Eep.  200. 

II  Field's  Medico-Legal  Guide,  p.  225. 

il  Seg.  on  Damages,  p.  38;  Field  on  Damages,  §  26;  Brool-e  vs.  Clarice,  57  Tex. 
105. 


SURGICAL    MALI'IiACTICE.  583 

resulting  from  tlie  disease  itself.  These  are  to  be  limited  to  the  addi- 
tional pain  and  snftVi-int>-  fansed  by  the  negligence  ov  want  of  proper 
care  and  skill  on  the  part  of  the  defendant.* 

Partnership  Liability. — In  case  two  or  more  snrgeons  are  associated 
together  in  joraetice  as  partners  all  are  liable  for  malpractice  by  any 
member  of  the  firm.t 

Action  Barred  by  Recovery  for  Services. — A  recovery  ])y  a  surgeon 
for  his  services  ^\\\\  l)ar  a  future  action  for  malpractice,  as  a  rule.  Ex- 
ceptions to  this  will  l)e  found  in  some  States  where  it  is  held  that  if  the 
recovery  be  by  confession  or  default  it  is  not  a  bar.  % 


CRIIVnNAL  LIABILITY  FOR  NEGLIGEXCE   OR  INOSCOXDUCT  UNDER   SPECIAL 
STATUTORY   PRO\^SIONS. 

As  previously  stated,  in  the  United  States  there  are  penal  statutes, 
differing  somewhat  in  the  different  States,  which  provdde  for  the  pun- 
ishment of  medical  practitioners  for  negligence  or  misconduct,  in  their 
professional  capacity  or  in  tlie  course  of  their  employment  or  business, 
which  causes  death.  The  law  is  held  to  apply,  in  sonje  States,  to  dealers 
in  drugs  and  medicines  who  by  carelessly  labeling  a  deadly  poison  as  a 
harmless  medicine  inflict  an  injury  or  damage  to  persons  without  fault 
on  their  i:)art. 

The  following  extracts  bear  upon  the  point  of  criminal  liability  for 
negligence : 

"  A  person  who,  by  any  act  of  negligence  or  misconduct  in  a  business 
or  employment  in  which  he  is  engaged,  ...  or  by  any  unlawful,  negli- 
gent, or  reckless  act,  .  .  .  occasions  the  death  of  a  human  1  )eing.  is  g-uilty 
of  manslaughter  in  the  second  degree." 

The  aliove  i^aragraph  has  been  held  to  apply  to  druggists  as  well  as 
to  practitioners.  § 

"  A  physician  or  surgeon,  or  person  practicing  as  such,  who,  being  in 
a  state  of  intoxication,  without  design  to  cause  death  administers  a  poi- 
sonous drug  or  medicine,  or  does  any  other  act  as  a  physician  or  surgeon 
to  another  person  which  causes  the  death  of  the  latter,  is  gnilty  of  man- 
slaughter in  the  second  degree."  || 


GENERAL   CRBIINAL   LLABILITY   AT   COJDIOX   LAW. 

Under  the  common  law,  as  well  as  under  special  statutory  enactments, 
a  physician  or  surgeon  who,  by  his  culpable  negligence,  causes  the  death 
of  his  jiatient  is  guilty  of  manslaughter.  A  person  who  nnla^N-fully  en- 
gages in  the  practice  of  the  profession  of  medicine  and  causes  death  by 
the  application  of  means  which  he  may  even  beheve  will  be  of  benefit  to 

*  Wcnger  vs.  CaUlcr,  78  111.  275. 

t  Uyrne  vs.  Erinu,  27  S.  C.  22G:  55  Am.  Rep.  15;  WhUtalcer  vs.  Collins,  34  Minn. 
299.      .. 

t  Rrnscqnle  vs.  Biiers.  52  Wis.  650;  38  Am.  Rep.  775;  Skiies  vs.  Bouuci;  1  Cin.  Sup. 
Ct.  4G4 ;  (iohlc  vs.  j}ill<>ii,  80  Iiul.  327 ;  44  Am.  Rep.  308 ;  14  Am.  and  Eng.  Encyel.  of 
Law,  83. 

SS  Penal  Code  of  New  York,  ^  195 ;  Thomas  vs.  TTiiichester,  6  N.  Y.  397. 

II  Penal  Code,  s^  200. 


584  -J    SYSTE2I  OF  LEGAL   MEDICINK 

the  patient,  would  be  guilty  of  manslaughter.*  Gross  ignorance,  gross'i 
carelessness,  rashness,  or  want  of  proper  precaution  on  the  part  of  such 
a  pretender  constitutes  manslaughter  at  common  law.t 

A  person  who  may  assume  to  act  as  a  physician  or  sui'geon  is  not 
criminally  liable  for  the  death  of  a  patient  caused  by  the  medicines 
which  he  administers,  provided  he  acts  in  good  faith  and  to  the  best  of 
his  abilities,  and  does  not  pretend  to  be  a  physician,  and  is  known  not 
to  be  such-i 

In  the  absence  of  statutory  provisions  upon  the  subject,  the  general 
rule  applies.  Under  this  a  regularly  quaMed  physician  and  surgeon 
legally  authorized  to  practice  his  profession  cannot  be  held  criminally 
responsible  for  an  honest  error  of  judgment  in  the  treatment  of  his- 
patient,  although  such  treatment  may  cause  his  death. §  Failure  on  his 
part,  however,  to  meet  the  requii-ements  of  ordinary  skill  and  diligence, 
the  death  of  the  patient  resulting  from  his  gross  ignorance,  inattention, 
or  carelessness,  or  from  criminal  misconduct,  being  shown,  he  would  be 
held  guilty  of  manslaughter  at  common  law,  if  not  under  statutes.  || 

Punishment  through  a  Criminal  Action  not  a  Bar  to  Recovery  in 
a  Civil  Action. — Finally,  it  is  to  be  noticed  that  in  case  a  physician  or 
surgeon  suffers  trial  and  punishment  for  malpractice,  either  under  special 
statutory  enactments  or  at  common  law,  this  does  not  constitute  a  bar 
to  a  civil  action  which  the  patient  may  bring  against  him  for  damages 
arising  from  such  malpractice.  The  fact  that  the  defendant  had  ah-eady 
suffered  punishment  for  the  offense  would  not  even  affect  the  rights  of 
the  plaintiff  in  such  an  action  in  recovering  punitive  damages,  where,, 
under  the  circumstances,  such  damages  are  allowable.*fj 

THE  MISHAPS  OF  SURGICAL  PRACTICE. 

GENERAL   CONSIDERATIONS. 

There  are  certain  accidents  occurring  after  injuiies  and  operations 
which  may  be  looked  upon  as  unavoidable  to  a  great  extent.  Among 
these  are  to  be  included  traumatic  delirium,  delu'ium  tremens,  fat  em- 
bolism, and  intoxication  by  fibiinous  ferments.  Among  the  accidents 
which  may  be  considered  as  unavoidable  under  some  circumstances  and 
avoidable  under  others,  may  be  mentioned  tetanus,  hemorrhage,  sepsis,. 
and  those  relating  to  the  use  of  anaBsthetics. 

Traumatic  Delirium. — Traumatic  dehrium  may  attack  old  and  en- 
feebled patients  as  well  as  those  who  were  in  perfect  health  prior  to  the 
occurrence  of  the  accident.  It  may  resemble  the  somewhat  peculiar- 
form  of  delu'ium  which  attacks  drunkards  following  an  injurj^,  the  symp- 

*  Marsh  vs.  Davidson,  9  Paige  (N.  Y.),  579. 

+  1  Hales,  P.  C.  (Eng.)  429 ;  4  Bl.  Com.  197 ;  Bex  vs.  St.  John  Lonfj,  4  C.  &  P.  (Eng.> 
432 ;  Hex  vs.  Van  Butcliel,  3  C.  &  P.  333 ;  Bex  vs.  Ellis,  2  C.  &  K.  Eng.  479 ;  Bex  vs. 
Spiller,  5  C.  &  P.  333 ;  Bex  vs.  Williams,  3  C.  &  P.  633. 

X  State  vs.  Shultz,  55  la.  628 ;  39  Am.  Eep.  187. 

§  Field's  Medico-Legal  Guide,  p.  192. 

II  Wheeler's  Criminal  Bejports  (N.  Y.),  p.  312;  Commonwealth  y?,,  Thompson,  6  Mass. 
134 ;  11  Am.  Rep.  122. 

%  Hendriclcson  vs.  Kingsbury,  21  la.  379 ;  Corwin  vs.  Walton,  18  Mo.  71 ;  Hadlcj/  vs.. 
Watson,  45  Vt.  289;  Boberts  vs.  Mason,  10  Ohio  St.  277;  Childs  vs.  Bralie,  2  Met. 
(Ky.)  146;  Field  on  Damages,  U  436-439. 


SLRGICAL   MALl'llACTK  K.  585 

tonis  of  iiial)ility  to  sleep,  anorexia,  and  delusions  bein^?  present  in  hotli. 
Prominent  among-  the  latter  may  be  mentioned  tlie  grasj)ing  at  imag:i- 
nary  small  animals  and  atti^mpts  to  escape  from  imag'inary  dangers.  The 
latter  are  much  more  pronounced  in  delirium  tremens,  however,  than  in 
traumatic  delirium. 

Fat  Embolism. — Fat  embolism  occui's  probabh'  in  almost  all  fract- 
ures to  a  greater  or  lesser  extent ;  in  addition  it  may  occur  where  there  is 
injury  to  the  stomach  or  T)owels  while  fat  wliicli  is  undergoing-  dig:estion 
forms  a  portion  of  the  contents  of  the  latter.  In  the  case  of  fractures 
the  fat  is  derived  mainly  from  the  medullar}'  cavity,  and  in  additi(jn  to 
this  source  it  may  be  deri\-ed,  to  a  certain  extent,  from  the  sul)Cutaneous 
connective  tissue.  The  fat  is  forced  into  the  opened  venous  channels  and 
is  taken  up  and  carried  along-  by  the  blood-current.  Even  in  patients 
who  die  almost  immediately  follomug  injuries  involving  fi-acture  of 
bones,  the  drops  of  fat  may  be  demonstrated  in  the  lungs  by  post-mor- 
tem examination.  The  particles  of  fat  are  broken  up  as  they  pass 
through  the  capillaries,  becoming  reunited  in  the  lai-ger  trunks,  until  at 
last  they  are  excreted  by  the  kidneys.  (Mausell  Moulin.)  While  in  the 
vast  majority  of  cases  no  s^anptoms  may  arise,  it  occasionally  happens 
that  collajise  comes  on,  too  late  to  be  attributed  to  shock,  but  superven- 
ing- after  an  interval  of  several  hours.  Dyspnoea  and  syncope,  with  rapid 
fall  of  temperature,  are  the  characteristic  s^nnptoms. 

Intoxication  from  Fibrin  Ferment — The  causes  of  intoxication 
from  fibrin  ferment  are  obscure.  This  is  looked  upon  as  one  of  the 
fever-producing-  agents  not  necessarily  of  a  septic  character  in  the  sense 
that  they  depend  upon  an  infective  organism.  The  source  of  the  filirin 
ferment  is  the  broken-down  blood-clot  f ollo^^'iug  hemorrhages.  It  follows 
subcutaneous  injuries  in  which  decomposition  in  the  sense  of  putrefac- 
tion does  not  take  place.  It  produces  one  of  the  varieties  of  traumatic 
fever,  the  temperatiu*e  rising-  in  proportion  to  the  amount  of  the  extrav- 
asation. It  is  more  than  probable  that  other  substances,  set  free  from 
crushed  and  bruised  tissues,  likewise  give  rise  to  traumatic  fever.  The 
height  of  the  fever  is  reached  in  aliout  twenty-four  hours ;  its  diu-ation 
■depends  upon  the  amount  of  irritant  material  present  and  the  extent  of 
its  absorption.  In  the  average  cases  the  fever  subsides  in  about  forty- 
eight  hours,  but  it  may  last  for  a  week  or  more,  the  fever,  however, 
steadily  falling  after  the  first  twenty-four  to  thii'ty-six  hours.  It  may 
assume  a  remittent  type. 

Tetanus  occurs  most  frequently  in  wounds  accidentally  inflicted,  par- 
ticularly in  j^unctured  and  penetrating  wounds,  and  in  those  in  which  a 
foreign  body  renuiins  behind.  Its  existence  is  now  believed  to  dei)end 
upon  the  presence  of  a  special  organism,  the  BdciUiis  fefaiii.  A  variable 
length  of  time  is  occupied  in  the  period  of  incubation,  according  to  the 
number  of  l)acilli  introduced  (Watson  ChejTie),  the  location  of  the  point 
of  infection,  the  anatomical  characteristics  of  the  siirrounding  tissues, 
and  the  capacity  of  the  different  tissues  to  yield  the  ptomaines  under 
tlie  influence  of  the  bacillus.  It  is  also  probable  that  the  degree  of  vini- 
lence  governs,  to  a  certain  extent,  both  the  duration  of  the  stage  of  incu- 
bation and  the  severity  of  the  attack. 

The  question  is  sonu^times  raised  as  to  the  propriety  of  remo%'ing 
foreign  bodies  which  have  remained  in  sifii  for  perhaps  months  in  those 
patients  in  whom  these  bodies  are  supposed  to  be  the  cause  of  the  dis- 


586  -i   SYSTEM  OF  LEGAL   JLEDICIXE. 

ease.  The  first  impnlse  is  to  remove  tlie  foreign  body  at  once,  but  tliere 
is  reason  for  believing  that  this  is  not  always  necessary,  and  in  some 
instances  may  do  hai-m,  the  disease  being  greatly  aggi-avated  by  even 
the  slightest  external  impressions.  The  modern  methods  of  ti'eatment 
of  the  disease  are  based,  in  fact,  npon  an  endeavor  to  absolutely  abolish 
everything  which  in  any  way  can  produce  an  impression  upon  the  nerves 
of  special  sense,  or  the  sensory  nei'ves  in  general.  If  the  foreign  body 
is  encap.sulated  and  an  incision  is  necessary  for  its  removal,  this  course 
would  be  more  than  likely  to  increase  the  dangers  of  the  disease  in  the 
manner  indicated.  This  rule,  however,  does  not  apply  to  the  removal  of 
the  foreign  body  as  a  preventive  measure ;  and  as  the  bacillus  of  tetanus 
requii'es  the  exclusion  of  oxygen  in  order  to  grow,  it  is  evident  that  a 
pimctured  wound  quickly  closed  offers  just  the  conditions  appropriate 
for  the  reproduction  of  the  germ,  if  it  has  been  introduced  into  the 
depths  of  the  wound.  In  wounds  of  this  character,  particidarly  if  they 
have  been  received  in  a  locality  where  tetanus  fi"equently  follows  tri\"ial 
wounds,  as  on  the  south  side  of  Long  Island,  the  wound  should  lie  weU 
cleansed,  and  enlarged  if  necessary  for  this  piu-pose,  and  ti*eated  with 
tampons  of  gauze  wi-ung  out  of  a  1-1000  bichloride-of-merciuy  solu- 
tion, and  healing  by  gi-anulation  encoiu'aged,  rather  than  union  by  fii*st 
intention. 

Uncontrollable  Hemorrhage. — This  is  among  the  most  nnfortimate 
accidents  of  surgeiy.  Rigidity  and  biittleness  of  an  artery,  or  its  retrac- 
tion beyond  oui*  reach,  in  spite  of  dilatation  or  even  enlargement  of  the 
wound,  may  bring  about  this  result.  HemoiThages  fi-om  large  venous 
trunks  are  the  most  dangerous.  Before  the  fact  that  hemorrhage  from 
a  large  vein  could  be  influenced  by  ligature  of  the  corresj^onding  arteiy 
was  established,  bleeding  from  the  internal  jugular  or  femoral  veins  was 
considered  as  almost  necessarily  fatal. 

In  hemophiliacs  the  sUghtest  operation  may  cause  an  almost  uncon- 
trollable hemorrhage.  The  apphcation  of  the  actual  cautery  is  most  use- 
ful, and  compression  is  sometimes  efficient.  If  the  compressing  medium 
is  such  as  to  imitate  the  finger,  i.e.,  impermeable,  elastic,  and  easily 
cleansed,  a  great  advantage  may  be  gained  by  its  use.  A  bunch  of  cot- 
ton or  a  soft  sponge,  WTapped  in  rubber  tissue,  the  layers  of  the  latter 
being  gummed  together  by  moistening  their  edges  with  chloroform  and 
pressing  the  moistened  sm-f aces  fimnly  upon  each  other,  answers  an  excel- 
lent pui-jiose.  Such  a  tampon,  if  kept  apphed  so  as  to  make  firm  com- 
pression and  to  dam  back  the  flow  of  blood  fi-om  the  point  at  which  it 
escapes,  will  be  found  an  efiicient  means  in  a  certaia  proportion  of  cases. 

The  mo.st  rapidly  fatal  cases  of  hemorrhage  are  those  in  which  septic 
processes — gangi-ene,  etc. — invade  the  structiu-es  of  the  vessels  them- 
selves. 

The  operation  of  transfusion  of  blood  requires,  in  order  to  carry  out 
the  necessary  precautions  and  technique,  the  consimiption  of  so  much 
time  that  siu'geons  are  coming  to  have  less  and  less  confidence  in  this 
procediu-e  as  an  available  means  of  combating  the  evil  results  of  excess- 
ive loss  of  blood.  AVithout  due  preparation  and  the  employment  of 
proper  instruments,  and  even  ^vith  all  these  conditions  fulfilled,  there  will 
occasionally  occur  such  aecid«Mits  as  the  injection  of  coagula  or  of  ah- 
with  the  tran.sfused  blood.  "VMiile  the  first-named  may  be  avoided  in 
saline  infusion,  without  due  care  the  second  may  occm\    As  to  how  much 


aUltClCAL   MALriUCTlt'E.  587 

benefit  may  be  derived  from  transfusion  of  blood,  or  saline  infusion  in  a 
given  case,'  or  how  niueli  the  surgeon  may  be  held  responsible  from  the 
scientific;  standpoint  for  failure  to  employ  it  in  fatal  cases,  is  yet  a  matter 
of  doubt.  As  far  as  my  own  exi)erience  goes  I  have  never  seen  a  case 
of  acute  aiuemia  benefited  ))y  either  of  these  procedures  that,  in  all  pi'ob- 
abiHty,  would  not  hav(^  done  well  without  such  interference.  Certainly  a 
nnich  larger  percentage  of  recoveries  in  extreme  cases  nmst  be  recorded 
before  a  sui-gcon  can  be  justly  blamed  for  omitting  to  use  them. 

Sepsis. — Within  the  last  quarter  of  a  century  there  have  been  dis- 
coveries made  and  j)rincii)les  established  in  the  treatment  of  so-called 
wound  diseases,  or  se(jiu'la^  of  wounds,  which  have  almost  completely 
changed  the  science  and  art  of  surgeiy,  and  increased  the  responsibility 
of  the  surgeon  to  an  extraordinary  degree.  Discoveries  in  the  treatment 
of  interual  diseases,  or  of  methods  of  preventing  them,  can  never  bring 
to  the  medical  practitioner  that  degree  of  increased  responsibility  which 
has  characterized  the  introduction  of  those  new  principles  in  the  treat- 
ment of  wounds  to  which  I  refer.  The  reason  for  this  is  ob\dous :  the 
medical  practitioner  never  prodvices  the  conditions  which  render  possible 
the  presence  of  the  disease  which  he  has  been  called  upon  to  treat,  and 
hence  his  measure  of  responsibility  does  not  extend,  to  an  extreme  de- 
gree, to  the  prevention  of  the  disease.  The  only  exception  to  this,  per- 
haps, will  be  found  in  those  comparatively  rare  instances  in  which,  dur- 
ing the  prevalence  of  an  epidemic,  such  a  demand  is  made  upon  the 
medical  num.  But,  as  a  rule,  he  finds  the  enemy  ah-eady  present  and 
intrenched,  perhaps,  behind  what  may  seem  an  impregnable  line  of  de- 
fenses,  and,  feeling  no  responsibihty  f(jr  his  presence  there,  his  dut}'  is 
simply  to  dislodge  him. 

The  same  remarks  might  apply  to  the  surgical  practitioner  in  his  rela- 
tion to  wound  treatment  if  it  were  a  fact  that  the  wounds  Avhich  he  is 
called  upon  to  treat  were  the  result  of  accident,  or  were  made  by  others 
than  hiniself.  But,  as  a  matter  of  fact,  two  thirds  of  the  wounds  which 
come  under  the  care  of  operating  surgeons  are  made  by  the  sui-geons 
themselves,  and  hence  his  responsibility  for  theii-  treatment.  Further 
than  this,  it  has  been  demonstrated  that  ahnost  all  disturbances  of  the 
repair  of  the  wound  itself,  and  in  addition  those  of  the  general  system 
with  their  dread  results,  known  under  the  general  term  of  blood-poison- 
ing, are  due  to  putrefactive  processes  which  have  their  origin  in  ferment- 
ative conditions  which  have  been  familiar  to  us  for  many  years.  With 
the  discovery  of  this  fact,  and  the  means  of  preventing  the  occurrence 
of  the  train  of  events  leading  up  to  its  full  development,  began  new 
obligations  and  responsil)ilities. 

From  the  earliest  times,  without  exactly  knowing  why,  surgeons  prac- 
ticed occlusion  of  wounds,  and  in  true  empuical  fashion  lauded  first  this 
and  then  that  ointment  or  lotion,  always,  however,  clinging  to  the  idea  that 
the  latter  must  cover  \\\e.  parts  and  "  protect "  them.  Wlien  the  idea  that 
contact  with  the  air  caused  mischief  in  the  wound  was  thought  of,  the 
temperature  of  the  air  was  generally  considered  to  be  the  origin  of  the 
troul)lc  ;  and  even  now,  among  the  laity,  it  will  Ik^  found,  as  the  result  of 
the  teachings  of  earli(>r  authorities,  that  any  mishap,  such  as  erysipelas, 
occurring  in  a  wound  is  attributed  to  ''catching  cold."  Ambroise  Pare 
added  to  the  theory  of  cold  the  belief  that  the  air  carried  with  it  certain 
miasms ;  and  Benjamin  BeU,  in  later  times,  taught  that  gases,  mingled 


588  -^    SYSTEM  OF  LEGAL  MEDICINE. 

with  the  air,  were  a  potent  source  of  evil.  UiidonLtedly  the  large  and 
varied  experiences  of  these  older  surgeons  led  them  to  plan  and  adopt 
many  methods  which  in  the  light  of  our  present  knowledge  would  pass 
fairly  well  for  antiseptic  procedures ;  and  without  doubt  the  use  of  wine, 
turpentine,  brandy,  alum,  common  salt,  etc.,  relatively  efficient  antisep- 
tics in  their  way,  was  by  them  considered  the  essential  portions  of  the 
balsams  and  ointments  then  in  use,  although  they  scarcely  dared  to  omit 
what  we  now  regard  as  the  superstitious  and  ridiculous  elements  of  these 
compounds,  such  as  serpents,  earthworms,  human  fat,  etc. 

In  the  earliest  times  one  thing  seems  to  have  been  entirely  lost  sight 
of,  namely,  the  intrinsic  tendency  on  the  part  of  wounds  to  heal  if 
left  alone.  No  one  dared  trust  anything  to  nature,  and,  in  the  absence 
of  the  usual  and  popular  measures  directed  toward  making  the  flesh  grow 
and  the  wound  cicatrize,  it  was  imagined  that  all  sorts  of  evil  would  cer- 
tainly occur,  and  that  healing  would  not  take  place.  In  those  times,  like- 
wise, there  seems  to  have  been  a  dread  of  healing  by  first  intention  or 
immediate  union.  Tents  or  pledgets  of  lint  were  crowded  constantly 
into  wounds  to  keep  their  edges  apart,  for  fear  of  pent-up  Immors  giv- 
ing rise  to  constitutional  disturbance — fever,  etc.  Thus  it  will  be  seen 
that  the  importance  of  drainage  to  the  parts  was  not  overlooked. 
Among  the  common  people  of  some  country  districts,  it  is  considered  a 
great  advantage  to  have  a  wound  "heal  from  the  bottom,"  as  they 
express  it. 

At  the  present  day  the  putrefaction  of  discharges  in  wounds  consti- 
tutes what  is  known  as  a  septic  condition  of  a  wound.  This  putrefaction 
depends  upon  a  fermentation,  which  may  or  may  not  be  accompanied  by 
the  development  of  offensive  odors.  Fermentation,  according  to  Fownes, 
may  be  defined  as  a  "new  arrangement  of  the  elements  of  an  organic 
compound,  and  the  consequent  formation  of  new  products."  Changes 
coming  under  the  head  of  this  definition  are  known  as  the  result  of  what 
is  termed  catalysis.  Ferments  are  divided  into  two  classes,  one  receiving 
the  name  of  "chemical  ferments,"  while  the  term  "vital"  is  usually  applied 
to  the  other. 

In  the  catalytic  change  known  as  chemical  fermentation  the  decom- 
position of  one  body  is  effected  by  the  mere  presence  of  another,  the 
latter  remaining  unchanged.  These  ferments,  as  has  been  again  and 
again  demonstrated,  have  not  the  power  of  self -multiplication.  _  Familiar 
examples  of  chemical  fermentation  may  be  cited  in  the  action  of  the 
pepsin  of  gastric  juice,  the  ptyaline  of  saliva,  etc.  On  the  other  hand, 
the  ferments  known  as  vital  ferments  possess  the  power  of  self-inulti- 
plication  in  a  remarkable  and  unhmited  degree.  The  yeast-plant  is  the 
most  familiar  example  of  this  last-mentioned  class.  In  1831  Braconnet 
advanced  the  opinion  that  microorganisms  acted  as  vital  ferments,  or 
that  they  produced  in  the  process  of  self-multipheation  virulent  prin- 
cijjles  which  acted  as  such,  although  this  had  been  suggested  in  the 
beginning  of  this  century.  In  the  next  five  years  followed  Downes's 
discovery  of  the  presence  of  microscopic  organisms  in  the  secretions  of 
certain  venereal  sores,  and  during  the  following  fifteen  years  Fnclis  and 
Pollender  demonstrated  tlie  presence  of  bacteria  in  tlie  blood  of  some  of 
tlie  lower  animals  suffering  with  septic  diseases,  notably  of  cattle  dying  of 
the  disease  known  as  charl)on.  But  it  was  reserved  for  Louis  Pasteur, 
in  1861,  to  bring  out  from  the  mass  of  imperfect  knowledge  of  the  sub- 


SURGICAL  MALPRACTICE.  589 

ject  at  that  time  availal)le,  and  to  add  thereto  as  the  result  of  his  owu 
brilliant  work,  facts  which  led  at  ouce  to  a  proper  coiiceptiou  of  the 
role  played  by  these  microorganisnis  in  the  production  of  disease.  The 
theory  of  the  i-elation  of  ])uti'efaction  to  fermentative  i)rocesses  was 
naturally  ap})lied  to  patholo^iical  conditions  at  once,  and  the  genius  of 
Lister  applied  the  principle  to  th(^  explanation  of  certain  phenomena 
following-  wounds  involving  the  surface  <rf  the  body.  The  beautiful  and 
simple  experiment  of  TynchiU  of  imprisoning  in  a  glass  tube  dust  from 
the  atmosphere,  and  showing  its  presence  )jy  the  aid  of  a.  fugitive  sun- 
beam impressed  into  the  service  for  the  time  being,  suggested  the  source 
-of  the  putrefactive  agents.  Thus  was  started  a  train  of  s(*ientific  re- 
search which  has  abnost  completely  revolutionized  the  surgical  world. 
The  literature  of  the  last  twenty  years  has  been  literally  teendng  with 
the  results  of  experiments,  until  there  has  s])rung  up  a  class  of  special 
workers  known  as  bacteriologists,  whose  further  researches,  by  means 
of  positive  methods  and  instrxuncnts  of  the  greatest  precision,  have  all 
tended  to  confirm  the  principle  laid  down  by  Listei',  and  upon  whicdi  is 
founded  the  nu^dern  treatment  of  wounds. 

Accessory  Wound  Diseases. — A  number  of  conditions  may  be 
grouped  together  under  the  head  of  accessory  wound  diseases,  any  one  of 
which  ma}'  occur  as  a  complication  following  the  infliction  of  a  wound. 
In  this  grouping  together  of  these  disorders  it  will  be  luiderstood  that, 
as  a  rule,  they  have  nothing  in  common  except  the  fact  that  they  are 
■due  to  the  presence  of  microorganisms.  As  Ijefore  stated,  these  ndcro- 
organisms  play  the  part  of  the  ferment,  and  set  up  changes  resulting 
in  putrefaction ;  a  nuiltiplication  of  the  original  ferment,  or,  in  other 
words,  an  increase  of  the  microbes,  occurring  at  the  same  time.  To 
this  putrefaction  or  growth  of  bacteria  are  due  t^e  much-dreaded 
diseases  erysipelas,  pya?mia,  septica?mia,  hospital  gangrene,  etc.  Starting 
Avith  the  propositions  that  subcutane(nis  injuries  rarely  suppurate,  and 
liicewise  that  they  heal  rapidh'  compared  to  open  wounds,  that  putre- 
factive changes  in  wounds  always  retard  their  healing,  and  that  it  has 
been  shown  by  carefully  conducted  experiments  that  the  injection  of 
putrid  fluids  into  the  blood  of  healthy  animals  will  produce  spnptoms 
which  can  only  be  compared  to  those  pathognomonic  of  septie  in- 
fection as  we  meet  it  in  vv'ound  diseases,  these  conditions  led  Lister  to 
apply  the  knowledge  thus  placed  at  his  disposal  to  the  development 
of  the  method  of  wound  protecti(ni  which  bears  his  name.  His  distinct 
aim,  as  shown  by  his  eai-liest  writings  upon  the  subject,  Avas  to  i)lace  a 
barrier  against  the  entrance  of  germs,  from  Avliatever  source,  including 
the  air,  into  and  about  wouiuls,  and  his  were  the  first  systematic  attempts 
to  formulate  and  put  into  practice  a  method  of  wound  treatment  based 
upon  the  germ  theory  of  the  origin  of  wound  diseases.  Trut%  carbolic 
acid,  Avhicli  he  first  employed  foi*  the  purpose  of  destroying  the  germs, 
as  well  as  other  substances  now  known  to  be  antiseptic  agents,  were  in 
use  in  the  treatment  of  Avounds,  but  not  as  germicides. 

Lister's  first  attempt  simply  brought  ridicule  upon  him  from  his  col- 
leagues;  he  AA'orked  steadily  on,  hoAvevi'r,  modifying  and  perfecting  his 
plans,  making  use  of  C(unnu)n  putty  nuxed  Avith  carbolized  oil  as  a  dress- 
ing, and  operating  luider  the  inadequate  protection  of  a  larg(^  carbolized 
sponge,  until  at  last  he  arrived  at  the  procedure  noAv  generally  known 
as  the  Listerian.    Less  cumbrous  dressings  and  troublesome  details  have 


590  -J   SYSTEM   OF  LEGAL  MEBICIXE. 

made  autiseptic  and  aseptic  siu-gery  a  less  formidable  undertaking  than 
in  the  past,  yet  the  results  obtained  by  those  who  follo^ved  rigorously 
his  teaehings  have  brought  us  well  beyond  the  threshold  of  a  new  era  in 
surgery.  A  point  worthy  of  note  in  this  connection  relates  to  the  exist- 
ence of  microbes  upon  aud  about  the  woimd  and  its  discharges,  in  sjjite 
of  the  apphcation  of  antiseptic  di'essings,  and,  coincidently,  an  uninter- 
rupted course  of  healing  on  the  part  of  the  wound.  Cheyne,  who  brought 
out  this  point  very  fully,  seems  to  regard  these  microbes  as  innocent,  so 
long  as  they  belong  only  to  a  certain  class.  Certain  it  is  that  fermenta- 
tion leading  to  putrefaction  does  not  alwa3^s  follow  upon  the  presence 
of  microorganisms.  There  can  be  no  reasonable  doubt  that  the  investi- 
gator of  the  futui'e,  mtli  improved  means  of  investigation,  will  demon- 
strate as  manj'  points  of  difference  between  these  minute  organisms  as 
are  now  known  to  exist  between  vertebrate  animals.  If  they  were  all 
equall}^  harmless  no  amomit  of  exposure  of  wound  sui-face  to  then*  influ- 
ence could  be  productive  of  evil ;  while,  on  the  other  hand,  if  they  were 
all  equally  hurtful,  none  would  be  found  in  the  ase]3tic  wounds. 

The  surgeon  of  bygone  times  performed  the  needful  operations  as 
skillfully,  perhaps,  as  it  could  be  done  to-day,  but  he  thereafter  relied  for 
the  final  reco"\"ery  of  the  patient  mainly  upon  good  fortune  and  means 
which  we  now  look  uj^on  as  inefiicient,  if  not  positively  harmful. 
As  a  result  the  measure  of  his  success  was  too  often  beyond  his  con- 
trol and  independent  of  his  own  efforts.  Tlie  surgeon  of  to-day,  how- 
ever, assumes,  in  the  main,  the  responsibility  for  the  after-course  of  the 
wound  he  inflicts :  the  occuiTcnce  of  any  accident  having  its  origin  in 
the  woimd,  and  the  result  of  these  diseases,  maj^  be  found  to  be  due  to 
conditions  to  a  great  extent  within  his  control.  The  development  dur- 
ing the  past  twenty  years  of  the  modus  operancll  of  a  successful  method 
of  wound  treatment,  based  upon  a  j^rinciple  which  previous  to  that  time 
had  never  entered  into  the  history  of  surgery,  has  arrived  at  such  a  state 
of  perfection  that  in  most  cases  of  carefully  planned  and  premeditated 
operation  a  fatal  result  should  not  occm-,  directly  traceable  to  the  wound 
itself.  Most  sm-geons  will  agree  that,  pro\dded  a  wound  does  not  in- 
volve some  organ  of  vital  importance,  and  does  not  prove  fatal  from 
shock  or  hemon'hage,  and  is  treated  with  rigid  regard  to  the  exclusion 
of  germs,  a  favorable  immediate  result  may  be  expected.  Its  edges  are 
not  inflamed  and  the  suiTOundiug  parts  are  not  greatly  swollen  nor  infil- 
trated. The  discharge  is  slight  and  is  genei-ally  the  oozing  of  a  clear  or 
but  slightly  tm*bid  fluid,  for  the  appearance  of  pus  containing  bacteria 
indicates  that  it  is  not  strictly  antiseptic.  Pro\dded  the  edges  of  the 
wound  are  well  coaptated  inmiediate  union  will  follow,  unless  the  sm*- 
rounding  parts  are  bruised,  or  the  A'essels  suppl^ying  the  parts  prevented 
fi'om  performing  their  function,  these  latter  conditions  favoring  death 
of  the  tissues  or  sloughing. 

The  aphorisms  of  aseptic  and  antiseptic  surgery  have  been  generally 
approved  and  acccepted  by  all  the  leaders  of  surgical  thought — in  other 
words,  the  authorities  of  t])e  present  day.  They,  therefore,  must  be  re- 
garded as  piinciples  of  practice  fii-mly  estal)lished,  and  be  respected  as 
such  until  new  theories  aud  procedures  are  advanced  and  accepted  regard- 
ing the  undoxil)ted  favoral:)le  infiuences  which  aseptic  measures  and  anti- 
septic agents  exert  over  the  process  of  wound  healing.  From  the  first 
moment  that  a  sm-gical  operative  case  involving  the  production  of  a 


SURGICAL   MALPIiACTK'E.  591 

■wound  comes  uuder  tlie  caro  of  tlio  surgeon  until  the  ease  is  concluded 
and  tlie  last  piece  of  bandage  is  removed,  these  principles  of  aseptic  and 
antiseptic  surgeiy  should  govern  the  action  of  the  surgeon.  Not  only 
will  tiny  control  the  (pu'stion  as  to  the  justifiability  of  oi)erating  at  all, 
))ut  as  to  the  particular  kind  of  oi)eration  best  adapted  to  maintain  a  proper 
condition  of  the  wound  ;is  regards  protection  and  drainage,  as  well  as 
the  methods  to  l)e  pursued  in  tlie  ci^nduct  of  the  operation  itself.  In 
explanation  of  the  assertion  that  tliese  principles  should  contj-ol  the  (jues- 
tion  of  th(!  justifiaJ)ility,  or  otherwise,  of  operating  at  all,  it  may  ];e  said 
that  operations  are  now  successfully  performed  which  heretofore  were 
either  unknown  or  condemned  almost  in  the  same  breath  in  which  they 
were  suggested.  Surgical  diseases  and  the  results  of  injuries,  as  a  con- 
sequence of  the  develoi)ment  of  the  principles  of  aseptic  and  antiseptic 
surgery,  are  now  amenable  to  operative  procedures  which  formerly  were 
consid(!red  as  emin(Mitly  of  a  fatal  character,  or  which  doomed  their  sub- 
jects to  lifelong  invalidism.  Tlie  surgeon  who  fails  to  resort  to  these 
new  opei'ations  because^  of  their  dang(_u-  when  pei-formed  according  to  the 
older  metliods  to  which  he  still  adheres,  or  who,  performing  them,  fails 
to  give  his  patient  the  advantages  of  the  protection  from  suppuration 
and  its  consequences  which  the  proper  canying  out  of  asej)tic  measures^ 
antiseptic  precautions  and  treatment  assures,  as  well  as  all  other  recog- 
nized means  at  his  command  for  the  furtherance  of  his  patient's  interests, 
cannot  escape  the  responsiljility  for  any  ill  results  that  may  follow.  The 
surgeon  who  fails  to  give  his  j^atient  the  benefit  of  the  immunity  from 
danger  which  the  aseptic  and  antiseptic  methods  secure  is  certainly  re- 
sponsible for  what  follows.  The  responsibility  is  growing  year  by  year, 
as  evinced  by  the  uttered  opinion  of  one  of  the  fii'st  surgical  authorities 
of  Europe,  the  late  Professor  Billroth,  of  Vienna,  who  has  said  that  fail- 
ures in  the  treatment  of  wounds  at  a  well-ordered  surgical  clinic  have 
become  as  rare  as  accidents  on  a  well-managed  railway. 

The  Surgeon's  Responsibility  for  Failure  when  Aseptic  and  Anti= 
septic  Principles  are  Violated. — The  rule  that  the  surgeon  is  in  a  gi-eat 
measure  responsible  for  the  evil  results  due  to  a  failure  to  ai)ply  the 
aseptic  and  antise})tic  principles  to  the  treatment  of  the  wounds  made 
liy  himself  will  not  be  invalidated  by  the  assertion  occasionally  made, 
that  there  are  still  surgeons  who  do  not  subscribe  to  the  claims  made 
on  behalf  of  aseptic  or  antiseptic  principles,  nor  use  methods  of  any 
kind  based  thereon,  and  who,  nevertheless,  obtain  quite  as  good  results 
as  do  those  who  claim  to  follow  these  rigidly.  A  study  of  the  methods 
employed  by  these  surgeons  will  frequently  reveal  the  fact  that  they  are 
most  scrupulously  clean  and  careful  in  all  their  procedures,  in  striking 
contrast  to  those  pursued  before  the  advent  of  antiseptic  surgery.  The 
plentiful  use  of  soap  and  water  to  cleanse  the  parts  to  hn  oi)erated  upon 
and  the  instruments  employed,  as  well  as  the  care  of  the  surroundings 
generally,  evince  a  belief,  if  it  is  not  definitely  expressed,  in  the  impor- 
tance of  excluding  noxious  matters  from  the  possibility  of  contact  with 
wound  surfaces.  Notwithstanding  their  disclaimers,  these  surgeons  \\y- 
tiially  practice  as(^])tic  surg(ay.  Those  exceptional  instances  in  which 
the  utter  disregard  of  the  enq)loym('nt  of  antisei)tics  is  noticeable  occur 
in  the  practice  of  certain  specialists  in  abdominal  surg<ny :  nnd  it  is  in 
the  class  of  cases  coming  uuder  the  care  of  these  most  expert  and  ra])id 
ojjerators,  in  which  cleanliness  is   assumed,  and  wound   surfaces   are 


592  ^   SYSTEM   OF  LEGAL   MEDICINE. 

■exposed  but  for  a  comparatively  short  time  to  the  action  of  germs,  that 
most  phenomenal  successes  occnr.  But  that  this  wUl  follow  in  general 
surgery  and  among  general  surgical  practitioners  it  would  be  most  absurd 
to  claim;  and  until  sm'geous  who  pursue  the  coiu'se  of  simple  clean- 
liness shall  estabhsh  this  or  some  other  procedure  as  the  safest  to  pur- 
sue in  the  different  branches  of  surgical  art,  the  antiseptic  as  well  as 
aseptic  principles  of  wound  treatment,  established  by  the  sanction  and 
practice  of  the  highest  authorities  in  the  world,  must  remain,  as  they  do 
to-day,  the  proper  basis  of  a  judicial  estimation  of  the  extent  of  the  re- 
sponsibility and  civil  obligation  of  the  operating  surgeon. 

Nothing  can  lessen  the  force  of  the  civil  obligation,  or  relieve  the 
responsibility  of  the  practitioner  who,  either  through  want  of  familiar- 
ity with  the  principles  and  practice  of  the  method,  or  a  failure  to  supply 
himself  with  the  necessarj'  appliances,  fails  to  give  to  every  patient  com- 
mitted to  his  care,  to  become  the  subject  of  an  operation,  if  ever  so  tri- 
fling, the  benefit  of  the  greatest  measiu'e  of  success  which  is  possible. 
There  is  scarcely  any  condition  in  life,  or  any  circumstances,  under  which 
the  application  of  these  principles  is  not  possible,  provided  they  are 
thoroughly  understood.  Certainly  in  operations  which  are  dehberately 
planned  there  can  be  no  question  about  the  truth  of  this  statement. 
Only  in  the  case  of  .wounds  accidentall}^  received  can  exception  be  taken 
to  this  rule.  Difficulties  of  technique,  cumbersomeness  of  nuiterials,  and 
the  possible  harm  to  the  patient  from  the  use  of  the  poisonous  antiseptic 
agents  employed,  have  all  been  urged  as  reasons  for  not  adopting  the 
antiseptic  treatment,  in  addition  to  the  expressed  disbelief  in  its  advant- 
ages and  in  the  truth  of  the  statements  made  by  its  advocates.  But 
complicated  typical  Lister  dressings  have  been  replaced  by  much  simpler 
means,  without  losing  any  of  the  advantages  to  be  derived  from  the 
original  methods,  and  antiseptics  of  a  non-poisonous  nature  are  available 
to  those  who  fear  to  use  the  more  powerful  germicides.  In  short,  the 
rules  are  so  simple  and  concise,  and  the  principle  so  easily  applied,  that 
no  surgeon,  located  even  at  a  point  remote  from  the  sources  of  supply  of 
the  di'essings  themselves,  can  have  any  valid  excuse  for  failing  to  follow 
them,  even  if  it  involves  tlie  improvising  of  dressings  from  such  crude 
materials  as  can  be  readily  obtained  in  the  humblest  abodes  of  the  poor. 

It  is,  therefore,  the  duty  of  every  surgeon,  when  treating  a  wound 
or  performing  an  operation,  to  use  a  rigorous  aseptic  procedure,  i.e.,  to 
prevent  sepsis,  and  employ  antiseptic  measures  in  addition,  in  cases  in 
which  septic  conditions  ali'eady  exist.  The  selection  of  tlie  methods  to 
be  employed  in  individual  cases  must  be  left  to  his  own  discretion,  how- 
ever, and  this  wiU  be  directed  by  his  own  scientific  convictions,  and  also, 
perhaps,  to  some  extent,  by  accidental  surrounding  circumstances  arising 
from  peculiarities  of  environment  of  the  patient. 

The  Surgeon  is  not  Bound  to  Follow  any  Specially  Planned  Pro= 
cedure. — The  principles  being  established,  no  special  procedure  can  be 
insisted  upon.  The  mere  covering  of  a  wound  with  a  piece  of  protective 
or  a  layer  of  antiseptic  gauze  does  not  constitute  an  aseptic  or  an  antisep- 
tic procedure,  however,  if  the  surgeon  does  not  use  them  correct^.  The 
selection  of  a  recognized  method  and  its  application  in  such  a  manner 
as  to  offer  a  barrier  against  infection  will  protect  the  surgeon  from  re- 
proach and  punishment  in  case  of  failure. 

In  protesting  against  holding  the  surgeon  responsible  in  case  he  does 


SUEGICAL  MALVRACTICE.  593 

not  follow  a  specially  planned  method  which  has  given  apparently  per- 
fect residts  in  the  hands  of  other  snrgeons,  no  more  forcible  argument 
can  be  employed  than  that  which  calls  attention  to  the  personal-e(| nation 
factors  as  they  relate  to  the  operator  as  well  as  to  the  individuality  of 
the  case  itself.  In  the  refinements  of  art  the  artist,  individually,  takes 
the  prominent  part  himself — ''  *SV  duo  faci  unit,  idem  non  est  idem.''^ 

Circumstances  may  arise  which  render  a  perfect  aseptic  or  antiseptic 
procedure  impossible,  such,  for  instance,  as  the  occiu-rence  of  a  severe 
hemorrliage  or  a  dangerous  narcosis,  where  all  other  considemtionsmust 
be  hdd  aside  in  order  to  meet  the  existing  exigencies -and  save  the  patient 
from  the  immediately  threatening  dangers. 

Accidental  Wounds. — In  the  case  of  accidental  wounds  already  in- 
flicted, and  at  a  depth  which  would  necessitate  a  grave  operative  proced- 
ure in  order  to  insure  complete  disinfection,  the  question  of  the  justifia- 
bility of  carrying  this  out  must  be  left  to  the  surgeon.  In  compound 
fractures,  for  instance,  with  but  a  small  wound  forming  a  communica- 
tion between  the  external  aii'  and  the  injury  to  the  bone  and  sm-rouuding 
soft  parts,  it  is  often  a  very  serious  question  whether  the  effort  to  reach 
the  depths  of  the  wound  may  not  open  up  new  channels  of  infection  and 
inflict  new  damage  upon  structures  whose  \dtal  resistance,  without  the 
infliction  of  this  added  traumatism,  might  be  able  to  withstand  the  effects 
of  already  existing  infection.  The  question  becomes  a  still  more  impor- 
tant one  when  the  problem  is  presented  of  oj^ening  into  important  ca^-ities 
of  the  body,  such  as  the  cranial  or  thoracic,  thus  invading  and  jeopar- 
dizing vital  organs. 

Aseptic  Precautionary  Measures. — Aside  from  these  extreme  in- 
stances, however,  the  duty  of  the  surgeon  is  plain.  To  cleanse  with  soap 
and  water,  to  shave  and  even  scrub  the  parts  siuTounding  the  wound,  is 
his  bouudeu  duty.  That  he  shall  apj^ly  dressings  which  are  free  from  all 
susx)icion  of  infection  is  but  an  additional  reasonable  demand.  With  the 
expenditure  of  a  little  time  and  slight  pains  the  fh'st  requirement,  i.e., 
the  cleansing,  can  be  accomplished.  Water,  with  the  addition  of  a  tea- 
spoonful  of  common  salt  to  each  pint,  wdl  thoroughly  sterilize  di-essiug 
materials  after  ten  minutes'  boiling,  if  these  be  only  strips  of  domestic 
cotton  or  linen  articles  torn  up  for  the  purpose.  Where,  however,  trust- 
worthy antiseptic  agents  are  at  hand  or  obtainable,  they  are  desii'able,  in 
addition,  when  cleansing  the  wound.  Failure  to  employ  the  latter,  how- 
ever, may  not  necessarily  lead  to  infection,  for  the  reason  that  all  acci- 
dentally inflicted  wounds,  even  when  exposed  for  a  time  to  accidental 
influences,  are  not  necessarily  infected  wounds.  The  infection  is  a  mat- 
ter of  pure  accident,  and  even  when  it  exists  the  tissues  may  be  in  a  con- 
dition to  resist  its  evil  influence.  Again,  Schimmelbusch  has  shown  that 
once  a  wound  has  become  invaded  by  microorganisms,  it  becomes,  not 
a  question  of  getting  rid  of  them,  but  rather  of  preventing  the  occiu*- 
rence  of  further  infection.  The  getting  rid  of  such  culture  material  as 
the  accumulated  wound  secretions  furnish,  by  means  of  proper  drainage, 
and  thus  preventing  the  proliferation  of  noxious  agents,  constitutes  a 
means  to  this  end,  in  addition  to  taking  such  precautious  to  prevent 
further  infection  from  without  as  are  comprehended  in  proper  cleansing 
of  the  surrounding  parts  and  the  application  of  sterile  dressings. 

Anesthesia. — Frequent  attempts  to  punish  surgeons  for  deaths  occm-- 
ring  wliile  an  anaesthetic  is  being  administered  tend  to  damage,  not  only 


594  -i   SYSTEM  OF  LEGAL  MEDIC IXE. 

tlie  profession,  but  society  at  large.  Tlie  great  benefit  wliicli  linmanitT 
has  received  from  tlie  use  of  these  agents  has  been  in  danger  of  being 
nullified  by  fear  on  the  part  of  the  administrator,  not  onl}"  of  damage  to 
his  professional  reputation,  but  of  being  j)unished  as  well.  Given  a  case 
in  which  a  pure  article  of  chloroform  or  ether  was  employed,  and  it  would 
be  difficult,  in  view  of  the  fact  that  differences  of  opinion  exist  as  to  the 
€xact  manner  in  which  anaBsthetics  act,  to  state  the  precise  mechanism 
of  the  fatal  issue,  and  hence  the  extent  of  the  resj)onsibility  of  the  sur- 
geon. Nelaton  even  advised,  in  Adew  of  the  difficulties  involved  in  de- 
termining beforehand  the  conditions  under  which  the  administration  of 
aneesthetics  could  be  safely  undertaken,  in  case  surgeons  were  mulcted 
in  civil  processes  under  circumstances  where  the  anaesthetic  agent  was 
of  good  quality  and  properly  employed,  that  they  should  combine  to 
renounce  the  use  of  anfesthetics  altogether.  Yelpeau  declared  that  to 
abandon  the  use  of  anaesthetics  would  injiuiously  affect  society  at  large 
more  than  it  would  the  sui'geons. 

An  Ansesthetic  should  not  be  Administered  without  an  Assistant. 
— ^An  ansesthetic  should  not  be  administered  without  an  assistant  except 
under  circumstances  of  emergency.  When  the  operator  is  compelled  to 
accept  the  ser\dces  of  a  non-professional  person  he  must  take  the  entire 
responsibility  of  the  administration.  When  the  assistant  administering 
the  anaBsthetic  is  a  regularly  quahfied  practitioner,  the  responsibility,  from 
the  professional  standpoint,  should  be  shared  by  both.  If,  however,  the 
operating  surgeon  can  be  justly  accused  of  selecting  an  assistant  who 
has  not  had  sufficient  experience  to  enable  him  to  give  the  aiieesthetic 
properly,  and  was  so  engaged  in  the  oj)eration  as  to  be  unable  to  person- 
ally superATse  the  administration,  then,  in  case  of  accident,  he  could  be 
held  liable  under  the  general  rule. 

Where  malpractice  is  charged  because  of  death  under  an  ansesthetie, 
the  fact  should  be  borne  in  mind  that,  before  the  discovery  of  angesthetic 
agents,  patients  suddenly  perished  just  before  or  during  operative  pro- 
cedures. These  deaths  have  been  attributed  to  various  causes.  When 
no  other  cause  could  be  assigned  it  was  said  that  the  patient  died  from 
fear  if  death  took  place  before  the  operation  had  really  commenced.  Of 
those  deaths  which  have  occiu'red  during  or  soon  after  the  operation,  the 
entrance  of  air  into  a  vein,  exhaustion,  the  result  of  debilitating  diseases 
or  gi-eat  loss  of  blood,  and  shock  are  to  be  held  accountable.  The  ele- 
ment of  fear  may  have  also  entered  largely  into  the  last-named  class  of 
eases,  before  the  introduction  of  chloroform  or  ether.  It  cannot  be 
denied  that  some  of  those  cases  which  have  perished  almost  in  the  veiy 
commencement  of  the  administration  of  an  anfesthetic,  and  before  a  suffi- 
cient amount  had  been  inhaled  to  reasonably  account  for  the  sudden 
lethal  exit,  may  have  been  unfavorably  influenced  by  the  same  causes. 
Tliose  who  have  had  a  large  experience  in  the  use  of  anaesthetics  believe 
that,  under  these  cii-cumstances,  the  ana?sthetic  failed  to  prevent  the  death 
of  the  patient,  rather  than  produced  it.  In  the  present  era  of  anamiii' 
and  nem'ous  women  such  instances  are  not  as  infrequent  as  one  Avouhl 
suppose ;  yet,  occuiTiug  under  such  circumstances,  the  almost  universal 
verdift,  in  the  popular  mind,  is  that  the  case  is  one  of  death  from  the 
anaesthetic.  Dupu^-tren,  the  famous  French  surgeon,  lost  no  less  than 
nine  patients  dimng  operations  mthout  the  Tise  of  anaesthetics,  and  Nuss- 
baum,  of  Munich,  lost  two  patients  just  prior  to  the  intended  operation. 


SURGICAL  MALPRACTICE.  59.") 

One  died  from  suffocation.  If  this  liad  happened  during  the  annpsthetiza- 
tiou  it  would  have  been  very  diflieult  to  convince  a  jury  of  laymen  that 
the  deatli  was  not  due  to  tlie  anaesthetic.  A  collapse  of  the  thiimed  earti- 
lag'es  of  the  trachea,  was  the  (niuse  of  the  suffocation.  Nussbaum  rehitcs 
a.n  instance  in  which  a  professional  friend  essayed  to  examine  a  strong 
countrywoman  witli  the  uterine  sound.  She  closed  her  eyes  and  was 
found  to  be  dead.  A  curious  instance  is  related  of  a  dentist  who  in- 
tended to  administer  an  aiuesthetic  to  a  patient  for  the  extraction  of  a 
tooth.  Tiiis  was  so  loosely  atta-(;hed  tliat  an  anaesthetic  was  not  thought 
to  be  necessary.  He  held  a  cupping-glass  under  her  nose  with  the  pre- 
tense that  it  was  an  ana\sthetizing  apparatus,  and  after  a  moment  pro- 
ceeded to  remove  the  tooth.  As  his  hand  approached  her  mouth  she 
was  found  to.  be  dead. 

Witnesses  to  Anassthetization  of  Female  Patients. — Tlie  necessity 
of  always  having  witnesses  at  hand  when  anaesthetics  are  administered 
to  female  patients  has  been  more  than  once  insisted  upon.  Experience 
shows  that  young  women  often  have  voluptuous  sensations  while  under 
the  influence  of  an  anaesthetic,  during  which  time  their  clothing  may 
become  soiled  with  mucus.  Upon  awakening  they  "\dll  affirm,  with  tlie 
greatest  positiveness,  that  they  have  been  violated  sexuall}'  during  the 
iina?sthesia.  This  may  arise  in  part  from  the  fact  that  women  fear 
that  the  person  administering  the  anasstlietic  might  take  advantage  of 
their  helplessness.  The  impression  may  continue  after  awakening,  the 
fear  being  changed  into  a  belief  of  the  impression  as  a  reality.  The 
importance  of  observations  upon  this  point  is  apparent  when  the  fact 
is  borne  in  mind  that  more  than  a  few  persons  thus  accused  have  suf- 
fered punishment,  although  in  the  light  of  subsequent  events  it  was 
deemed  more  than  probable  that  they  were  innocent. 

Cause  of  Death  Difficult  to  Establish  when  Anaesthetics  are  Em= 
ployed. — Giving  to  the  difficulties  of  excluding  other  causes  of  death  in 
a  particular  case,  fatal  anasthesia  narcosis  is  not  easy  to  establish. 
This  is  i)articularly  true  where  the  operation  has  advanced  sufficiently 
far  to  allow  the  element  of  shock  to  enter  into  the  case.  Reflex  irritation 
of  the  cardiac  centers,  giving  rise  to  lessened  force  combined  with  accel- 
eration and  intermitteney,  this  eventuating  in  the  arrest  of  the  heart's 
action,  occurs,  especially  when  chloroform  is  administered.  The  sudden 
breaking  up  of  adhesions  within  a  joint,  or  dilatation  of  the  anal  sphinc- 
ters, has,  not  infrequently,  been  followed  by  the  development  of  dan- 
gerous sym])t()ms.  In  the  case  of  the  latter  it  is  advised  to  withdraw 
the  anasthetic  beforehand,  in  order  that  the  few  spasmodic  inspirations 
which  the  patient  takes  immediately  following  the  forcible  stretching  of 
the  sphincter  may  not  carry  into  the  circulation  through  the  vessels  of 
the  pulmonary  system  a  sudden  and  overwhelming  dose  of  the  anasthetic. 

Wliere  the  element  of  shock  enters  largely  into  the  condition  there 
can  be  no  question  as  to  the  freedom  of  the  surgeon  from  responsil)ility 
in  the  sudden  collapse.  Reflex  paralysis  of  the  respiratory  or  cardiac 
centers,  the  first  from  ether  and  the  second  from  chloroform,  has  bet'U 
thought  to  be  produced  b}^  irritation,  primarily,  of  the  distri))ution  of 
the  trigeminous  and  pneumogastric  nerves,  particularly  when  large  quan- 
tities of  the  aua\sthetic  have  been  employed  at  the  very  commencement 
of  the  administration.  In  \'iewof  the  fact  that  the  use  of  an  anasthetic 
in  a  hurried  manner,  or  "  crowding  the  anasthetic,"  as  it  is  called,  at  the 


596  ^   SYSTEM  OF  LEGAL  MEDICINE. 

very  commencement,  is  but  rarely  called  for,  tlie  responsibility  of  the 
siu'geon  is  greater  if  death  follows  such  a  method.  The  drop-by-drop 
method  insures,  to  a  great  extent  at  least,  immunity  from  danger  from 
these  somxes. 

Infliction  of  Pain  when  Patient  is  but  Partially  Anaesthetized. — 
While  profound  narcosis  is  not  deemed  essential  for  everj^  o^Dcration,, 
notably  those  of  comparatively  short  duration,  yet  the  sudden  infliction 
of  great  pain,  the  patient  being  but  slight^  under  the  influence  of  the 
antesthetic,  has  resulted  in  the  sudden  supervention  of  reflex  cardiac 
paralysis.  This  is  more  apt  to  occm^  when  chloroform  instead  of  ether 
is  used.  This  has  likewise  been  considered  a  cause  of  death,  even  when 
the  patient  has  been,  to  all  ap]3earances,  completely  under  the  influence 
of  the  anaesthetic.  It  must  appear  at  a  glance  that  the  surgeon  could 
scarcely  be  held  accountable  under  such  circumstances. 

Post=niortem  Appearances  in  Fatal  Chloroform  Narcosis. — Among 
the  causes  of  death  which  are  said  to  be  demonstrable  anatomically  in 
those  who  have  perished  from  alleged  overdoses  of  chloroform  that  of 
fatty  degeneration  of  the  heart  is  most  prominent,  yet  even  here  there  is 
room  for  reasonable  doubt.  Patients  have  taken  anaesthetics  even  under 
these  circumstances,  and  dui-ing  the  following  fortnight  died  of  heart 
failure  due  to  an  apparently  sUght  but  sudden  movement  of  the  body. 

Indirect  Causes  of  Death  from  An£esthetics. — The  induect  causes  of 
death  in  fatal  narcosis  from  chloroform  or  ether  are  somewhat  numerous. 
Aspiration  of  vomited  material  or  blood-coagula,  in  operations  about  the 
mouth  and  throat,  these  flnding  their  way  into  the  air-passages,  may 
result  in  suffocation.  These  do  not  properly  belong  in  the  category  of 
cases  of  fatal  narcosis,  yet  the  question  may  arise  as  to  whether  or  not 
proper  precautions  in  the  way  of  having  ordered  that  no  food  be  taken 
for  a  sufficient  length  of  time  beforehand,  and  in  how  far  a  proper 
position  of  the  head  (Kose's  dependent  head  position),  or  the  aid  of 
competent  assistants  in  keeping  the  glottis  clear  of  blood-clot  by  spong- 
ing, or  the  performance  of  preliminary  tracheotomy,  might  have  averted 
the  catastrophe.  Unless  the  person  engaged  for  the  administration  of 
the  anaesthetic  has  been  likewise  intrusted  with  the  proper  preparation  of 
the  patient,  the  surgeon  can  scarcely  be  held  negligent  if  death  be  due 
to  the  aspiration  of  vomitted  material.  The  operator  himself  must  see  to- 
it  that  the  passage  of  blood  coagida  into  the  larynx  is  avoided,  if  possible. 
In  neither  case  can  the  manner  or  method  employed  in  administering  the 
anaesthetic  be  held  responsible,  although  it  is  true  that  patients  will  have 
violent  retching  attacks  when  coming  out  from  under  the  ether ;  hence 
by  keeping  them  well  under  the  ana?sthetic  influence  these  retching  efforts 
^vill  be  avoided.  These  latter,  unless  there  is  food  in  the  patient's  stomach, 
will  do  but  little  harm  beyond  embarrassing  the  operator  in  his  work.  The 
respirations  may  fail  from  convulsive  closure  of  the  glottis,  from  falling 
backward  of  the  tongue  dm-ing  profound  narcosis,  or  from  the  latter 
being  drawn  convulsively  backward.  Spasmodic  closure  of  the  lips  and 
jaws  must  also  be  guarded  against,  and  should  not  escape  the  attention 
of  the  angesthetizer,  as  asphyxia  may  result  from  this  want  of  precaution. 

Cases  of  fatal  suffocation  by  artificial  teeth,  chewing-tobacco,  and 
even  mucus  have  been  reported.  An  inflammatory  swelling,  following' 
the  passage  of  a  portion  of  the  ana^.sthetic  in  a  liquid  state  into  the  re- 
spiratory passages,  flexion  of  the  trachea  from  torsion  of  the  neck,  and 


SURdlCAL   MALI'RACTICE.  01)7 

mechauical  pressure  upon  the  thorax  or  abdomen  may  likewise  cause 
asphyxia. 

Death  under  Anzesthesia  Following  Severe  Traumatism  or  during 
a  Chronic  Disease. — A  fatal  result  oecuiTing-  in  connection  with  a  severe 
traumatism,  as,  for  instance,  a  severe  head  injury,  rupture  of  intestine, 
intraperitoneal  hemorrhag-e,  or  a  neglected  intestinal  obstructicni,  the 
strength  of  the  patient  l)eing  already  greatly  decreased — even  though  he 
perishes  almost  immediately  after  amesthesia  is  established — the  surgeon 
is  not  to  l)e  held  responsil)le.  On  the  other  hand,  a  patient  suffering 
from  a  clu'onic  disease,  as,  for  instance,  phthisis  pulmonalis,  and  to  whom 
an  ajuestlietic  is  given,  say,  for  the  reduction  of  a  dislocation,  if  a  fatal 
resnlt  follow  immediately  upon  the  administration  he  nmst  be  considered 
as  having  dii^l  from  the  effects  of  the  anaesthetic,  although  the  operator 
may  be  lield  l)lanieless. 

Direct  Cause  of  Death  in  Chloroform  Narcosis. — The  du-ect  cause 
of  death  when  chloroform  is  employed  as  an  anaesthetic  is  paralysis  of 
the  heart  with  subsequent  asphyxia,  and  anaemia  of  the  brain.  In  addi- 
tion to  the  sudden  paralysis  of  the  heart,  occurring  with  or  without  the 
common  degenerative  changes,  long-continued  narcosis  with  chloroform 
may  induce  degenei-ative  changes  in  the  heart  muscle.  Furthei'morCy 
repeated  chlovoformization  has  l)een  accused  of  producing  fatty  degen- 
eration of  the  heart  muscle.  In  those  suffering  pre^iously  from  pulmo- 
nary affections,  bronchopneumonia  may  develop  from  defective  lieart 
action ;  circulatory  disturbances,  edema,  and  inal)ility  to  rid  the  bronchi 
of  accumulated  secretions  contributing  thereto.  Ether  as  well  as  chloro- 
form may  tend  to  produce  this  condition,  the  former,  in  addition,  lead- 
ing to  increased  secretion  along  the  respiratory  tract. 

"  Effects  of  Anaesthetics  upon  the  Kidneys. — Renal  affections  may  re- 
sult fi-om  either  cldorofoi-m  or  ether.  Contrary  to  what  has  been  gener- 
ally supposed,  Wnnderlich  *  has  shown  that  the  latter  agent  is  not  alone 
in  its  su})posed  damaging  effects  upon  the  kidueys.  From  his  extended 
observations  of  the  effects  of  the  two  anaesthetics  upou  the  reual  organs, 
he  makes  the  following  deductions:  (1)  An  already  existing  allumiiuuria 
is  often  increased  by  etherization.  (2)  x\lbuminuria  can  be  caused  by  nar- 
cotization with  both  chloroform  and  ether,  but  more  frecpiently  with 
chloroform.  With  the  latter  this  resulted  in  11.5  percent,  of  the  eases ;  with 
ether  it  occurred  in  only  6.9  percent.  (3)  Casts  appeared  in  the  urine 
after  both  chloroform  and  ether,  but  more  frequently  following  the 
former.  This  occurred  after  chloroform  in  34.8  percent,  of  the  cases, 
and  followed  ether  in  2-}:.()  percent,  of  the  cases.  (-4)  When  casts  are  al- 
ready present,  both  ether  and  chloroform  have  the  effect  of  increasing 
the  nund)er.  It  follows,  therefore,  that  both  anaesthetics  must  be  used 
cautiously,  as  both  have  the  power  of  setting  up  degenerative  changes  in 
the  renal  epithelia.  Anaesthetics  in  general  and  chloroform  in  particular 
should  be  avoided  in  persons  who  tin-n  suddenly  pale,  with  dilated  pupils, 
or  who  are  excessively  timid  and  faint  easily.  According  to  Bardeleben, 
excitement  and  fear  before  and  during  the  administrati(ui  of  the  anaes- 
thetic do  more  harm  than  the  latter,  wliatever  its  miture. 

Respiratory  and  Cardiac  Indications. — As  far  as  the  respiratory  and 
cardiac  indications  are  concerned,  Kocher  reconnnends  to  employ  ether 

*  Beifnige  ~iir  l-Uni.'>ehc)i  CJiinirgie,  Band  xi. 


598  ^  SYSTJiM  OF  LEGAL  MEDICIXE. 

exclusively  in  cases  of  affections  of  the  heart  not  combined  with  respii-a- 
torv  distnrliances,  and  chloroform  in  affections  of  the  respii'ator}*  organs 
with  hypertemia  of  the  tracheal  and  bronchial  mucous  membranes,  or  other 
obstacles  to  res]3u*ation. 

Even'  such  contraindication,  however,  is  only  relative,  each  ease 
being  carefull}-  considered  in  relation  to  the  si^eeial  conditions  present. 
In  urgent  cases,  such,  for  instance,  as  strangulated  hernia,  it  may  occur 
that  either  one  or  the  other  may  be  employed  from  force  of  cii'cum- 
stauces.  While  the  question  of  i3roper  selection  of  the  anaesthetic  may 
be  of  importance  from  the  scientific  standpoint,  its  relations  to  possible 
charges  of  neghgence,  in  the  present  state  of  oiu'  knowledge,  can  scarcely 
enter  into  the  controvers}'. 

Chloroform  Idiosyncrasy. — There  is  a  condition  known  as  the  chlo- 
roform idiosjTicrasy,  which,  however,  can  only  be  recognized  during 
the  attemj)t  to  administer  this  anesthetic.  Soon  after  the  first  inspira- 
tion the  patient  becomes  pale  and  springs  from  the  talkie  with  terror 
and  great  anxiety,  declaring  that  he  is  suffocating.  Almost  immedi- 
ately he  passes  into  a  swoon,  from  which  he  is  aroused  ^^ith  difficulty. 
At  the  same  time  the  pupils  become  dilated,  and  strabismus  may  occur, 
with  clonic  convulsions  of  the  upper  and  lower  extremities.  On  the 
other  hand,  some  patients  exhibit  a  sort  of  chloroform  or  ether  hun- 
ger, inhaling  immense  quantities  in  a  short  time  by  means  of  extraordi- 
narily vigorous  respiratory  efforts.  Both  of  these  classes  of  cases  reciuii'e 
careful  watching  on  the  part  of  the  anesthetizer.  In  the  fii'st  the  anaes- 
thetic agent  should  be  changed  to  ether,  and  it  may  be  necessary  to 
abandon  for  the  time  being  all  efforts  at  anfesthetization. 

Patients  should  be  watched  carefully  for  several  houi"s  after  anes- 
thetization, particularly  when  chloroform  has  been  employed.  Dyspnoea 
and  cardiac  failm-e  may  demand  attention. 

Quantity  of  Ansesthetic  Employed. — When  accusations  are  made 
that  unusLially  large  cpiantities  of  the  anesthetic  agent  have  been  used, 
it  would  be  well  to  bear  in  mind  Mair's  *  statements  bearing  upon  this 
23oint.  This  author  states  that  patients  have  inhaled  160  grams  of  chloro- 
form in  seven  hours ;  1023  grams  in  twenty-foui"  hours  in  another  case ; 
in  another,  suffering  from  tetanus,  700  grams  in  twenty-four  hours ;  in 
another,  1000  grams  in  twelve  hours;  a  woman  in  the  puerperal  state 
remained  chloroformed  for  thii'teen  hours,  200  grams  being  used.  In- 
stances are  recorded  where  patients  haliitually  took  500  grams  daily  for 
five  or  six  days  without  injury.  A  ease  is  related  by  Nussbaum  in  which 
this  siu-geon  anesthetized  with  chloroform  a  patient  fifty-thi-ee  times 
for  the  purpose  of  passing  uretln-al  sounds.  This  patient  succumbed  to 
the  fiftj'-fourth  anesthetization.  Upon  this  occasion  laughing-gas  was 
employed.  The  post-mortem  examination  showed  disintegi^ation  of  the 
blood-corpuscles,  etc. 

Methods  of  Ansesthetization. — As  to  methods  of  anesthetization  by 
means  of  chloroform,  authorities  are  agreed  that  this  agent  should  be 
given  largely  diluted  ■s\'ith  atmospheric  air,  and  that  it  should  never  be 
I)oured  but  always  dropped  upon  tlie  napkin  or  mask.  The  pulse  should 
be  carefuUy  watched,  and  note  made  of  au}^  change  of  color  in  the  face, 
the  occurrence  of  superficial  breathing,  or  the  supervention  of  loud  snor- 

*  Gerichtlicli-mcdiciriisclie  Casuistic  tier  Knnstfehler. 


srnair.iL  mali'Ractick.  599 

iiig-.  If  the  pulse  beeomes  weak,  tlie  respirations  shallow  or  stertorous, 
or  the  color  i)ale  or  livid,  the  cliloroforui  must  he  at  ouce  withdrawn. 
Coini)lete  narcosis  is  announced  l»y  relaxation  of  the  inusch's  and  the 
absence  of  oeular  retlex. 

Precautionary  Measures. — Precautionar}-  measures  consist  in  i)lac- 
ing  the  patient  in  the  horizontal  position ;  by  some  surg-eons  it  is  even 
required  tluit  the  head  be  lowered,  the  body  assuming  an  angle  of  forty- 
five  degrees.  The  precaution  relating  to  an  empty  condition  of  the  stom- 
ach has  already  been  alluded  to.  Obstructions  to  full  respiratitm,  such 
as  the  presence  of  a  collar,  or  a  cravat,  or  a  tight  neck-band  of  the  shirt, 
etc..  should  be  removed  or  loosened. 

Treatment  of  Dangerous  Chloroform  Narcosis. — In  cases  of  danger- 
ous narcosis  from  chloroform  the  aii'  is  to  be  permitted  to  pass  freely 
about  the  patient,  who  should  also  be  violenth'  shaken  and  perhaps 
Nelatonized  (suspended  by  the  feet) ;  water  dashed  into  the  face ;  artifi- 
cial respiration  instituted ;  i)erhaps  a  catheter  introduced  into  the  larynx, 
or  a  tracheotomy  performed ;  mouth-to-mouth  l)reatliiiig  practiced  :  the 
phrenic  nerve  faradized,  one  pole  being  placed  over  the  scaleni,  low  down 
in  tlie  neck,  and  the  other  at  the  lower  costal  margin  ;  the  heart  stimu- 
lated by  means  of  hot  cloths,  and  perhaps  acupuncture ;  inhalation  of 
oxygen.  In  order  to  permit  the  free  access  of  air,  tlie  pharmx  is  to  be 
cleaned  and  the  tongue  drawn  forward  b}'  means  of  a  tongue-forceps. 
A  lateral  gag  in  the  mouth  is  useful  in  addition. 

In  Koenig's  clinic  at  Giittingen,  in  cases  of  chloroform  syncope,  sim- 
ple compression  of  the  cardiacs  region  is  employed  in  place  of  the  ordinary 
artificial  respiration.  ^laas*  reports  two  very  striking  cases  illustrative 
of  this  method  of  ti-eatment.  In  l)oth  the  respiration  had  ceased,  the 
radial  pulse  was  absent,  and  the  pupils  were  Tvidely  dilated.  The  move- 
ments were  continued  for  over  an  liour.  The  compression  is  made  by 
placing  the  foot  upon  the  patient's  left  thorax  and  making  quick  move- 
ments of  pressure  over  the  cardiac  region  at  the  rate  of  one  hundred  and 
twenty  times  or  more  a  minute.  The  right  half  of  the  chest  is  steadied 
at  the  same  time, 

Dangerous  Vomiting  Following  an  Ancestbetic. — The  after-vomit- 
ing nuiy  prove  a  dangerous  sequel  to  the  administration  of  an  ana^sthetic, 
and  should  receive  attention  at  the  surgeon's  hands.  The  taste  of  the 
xin{i?stlietic  increases  the  fiow  of  saliva,  and  as  the  expelled  air  contains 
more  or  less  of  the  anaesthetic  agent  for  some  time  afterward,  the  secre- 
tions of  the  mouth,  loaded  with  this,  are  swallowed  and,  irritating  the 
gastric  muc(ms  membrane,  provoke  intense  nausea  and  per.sistent  vomit- 
ing. The  patient  should  be  encouraged  to  eject  the  accunnilations  in  the 
mouth.  Lavage  with  a  one-lialf  to  two  percent,  carboiuxte-of-soda  solu- 
tion is  frequently  effectual  in  aff(U-ding  relief. 

The  Use  of  Chloroform  at  Night.-^The  use  of  chlorofcmn  at  night 
is  to  be  av(^ided  as  much  as  possiT)le.  It  is  a  common  experience  under 
these  circumstances  to  observe  some  peculiar  effects,  such  as  a  tendency 
to  vomit,  an  irritative  cough  ■v\dth  subsequent  developnient  of  broncliitis 
and  severe  catarrhal  pneumonia.  These  are  supposed  to  be  due  to  com- 
l)inations  between  the  vapor  of  the  chloroform  and  the  products  of 
combustion. 

*  Berliner  KUn.  Wocheuaelirift,  No.  12,  1802. 


(500  ^   SYSTEM  OF  LEGAL  MEDICINE. 

The  Administration  of  an  Anaesthetic  to  Pregnant  Women. — The 

admiuistration  of  an  antestlietic  to  pregnant  women,  for  operations  of 
convenience,  or  for  such  operations  as  can  be  readily  performed  without 
an  anaesthetic,  as  the  opening  of  an  abscess  or  the  extraction  of  a  tooth, 
has  been  the  subject  of  inquir3^  In  the  opinion  of  some  authorities  the 
production  of  abortion,  or  the  induction  of  prematm-e  labor,  in  this  con- 
nection may  result,  even  though  the  narcosis  is  of  but  short  dui-ation ; 
wliile  others  are  equally  confident  that  the  anesthetization  has  nothing 
whatever  to  do  mth  the  untoward  i-esult,  if  any  such  follow,  but  that 
the  latter  is  either  a  coincidence,  or  can  be  more  pi'operly  attributed  to- 
the  operative  procedure.  There  are  many  difficulties  in  the  way  of  de- 
ciding this  question,  inasmuch  as  anaesthesia  is  induced  under  conditions 
where  some  operative  procedure  is  to  be  performed,  and  in  patients 
peculiarly  susceptible  to  mental  influences ;  the  anxieties  incident  to  the 
administration  of  the  anesthetic,  as  well  as  those  arising  from  fear  as  to- 
the  outcome  of  the  operation,  to  say  nothing  of  the  fear  of  an  interrup- 
tion of  the  normal  gestation,  may  all  combine  to  bring  al^out  an  unfor- 
tunate result,  irrespective  of  the  effects  of  the  anaesthetic  itself.  The 
surgeon  can  have  no  choice  but  to  subject  the  patient  to  the  risks  of  the 
anaesthetic  just  as  he  would  to  the  other  risks  of  the  operation,  where 
this  is  one  of  necessity  and  involving  great  suffering  should  its  perform- 
ance be  undertaken  without  an  anesthetic. 

Unusually  Prolonged  Anaesthesia. — The  possibility  of  an  unusually 
prolonged  anesthetic  effect  cannot  be  denied,  especially  in  the  case  of 
chloroform.  These  cases  seem  to  resemble  those  in  which  the  extreme 
effects  of  carbon  dioxide  have  been  suffered  from.  They  are  character- 
ized by  slow  and  incomplete  return  to  consciousness  and  sensibility  after 
from  forty-eight  hours  to  three  days.     Con\ailsions  may  occur. 

In  cases  of  chronic  alcoholism,  in  which  paralysis  and  extreme  nerve 
exhaustion  contribute  largely  to  jDrodiice  the  fatal  result,  the  latter  may 
enter  in  such  a  manner  as  to  sunulate  death  from  the  protracted  effects 
of  cliloroform. 

Objections  to  Ether. — Ether,  particularly  if  a  pm-e  article  is  not  used, 
produces  irritation  of  the  mucous  membrane  of  the  respii-atory  passages 
to  an  extent  sufficient  to  cause  bronchitis  or  catarrhal  pneumonia.  As 
has  been  already  shown  by  Wunderlich's  studies,  its  influence  upon  the 
renal  organs  has  been  greatly  overestimated  in  the  past.  The  inflamma- 
bility of  the  vapor  of  this  anesthetic  agent  introduces  an  element  of 
danger  when  the  oj)eration  is  performed  near  an  open  flame,  or  where 
the  thermocautery  is  employed  in  operations  about  the  head. 

Occasional  Similarity  of  Dangerous  Symptoms  in  Chloroform  and 
Ether  Narcoses. — The  causes  of  death  from  cliloroform  are,  to  a  cei'tain 
extent,  the  same  as  those  from  ether.  Distinctions  have  been  made  as- 
to  the  manner  in  Avhich  the  alarming  sj^mptoms  enter,  as  well  as  the 
vital  organs  first  affected.  Wliile  in  general  it  is  true  that  heart  failure 
charactej'izes  dangerous  chloroform  narcosis,  and  failure  of  the  respira- 
tory function  that  from  ether,  jei  the  fact  remains  that  in  many  cases 
patients  wiU  cease  to  breathe  under  chloroform  while  the  heart  is  in  no 
wise  disturbed  in  either  its  force  or  frequency,  on  the  one  hand,  while,  on 
the  other,  it  is  not  infrequently  observed  that  patients  under  ether  will 
suffer  from  failure  of  the  cardiac  impulse  while  the  respiratory  move- 
ments are  but  sUghtly,  if  at  all,  affected.     If  the  person  administering- 


srnaicAL  malpractice.  GUI 

the  anaesthetic  were  to  wait  for  the  pallor  of  the  surface  which  is  sup- 
posed to  be  tlie  signal  of  dan^^er  in  clilorofonn  narcosis,  he  wcndd  Ije 
•deceived  as  to  the  condition  of  the  patient,  for  the  reason  that  this  is  sel- 
dom observed,  and  is  but  transient  when  it  does  occur.  The  patient 
is  nni(;h  more  likely  to  exhibit  the  appearances  of  carbon-dioxide  in- 
toxication, with  somewhat  pronounced  cyanosis,  than  the  spnptom  of 
paUor. 

In  g-eneral  terms,  however,  it  may  be  stated  that  while  the  symptom 
of  cyanosis  is  present  in  both  cases,  in  so  far  as  our  present  knowledge 
of  the  action  of  these  agents  goes,  in  chloroform  narcosis  this  depends 
upon  (lefieient  oxygenation  of  the  bhjod  from  stasis,  wliile  with  ether  it 
is  d(;pendeiit  upon  true  asph^'xia  from  respiratory  obstruction  or  failure. 
That  there  are  numerous  exceptions  to  this  rule,  however,  as  before  stated, 
tliere  can  be  no  question.  The  fact  nevertheless  remains  that,  wliile  this 
cyanosis  oecurring  in  the  course  of  the  administration  of  ether  comes 
on  gradually-,  it  is  quite  readily  remedied  by  the  free  access  of  au*  for  a 
short  time,  and  is  not  an  alarming  symptom  unless  it  persists  in  spite  of 
the  removal  of  the  ana?sthetic.  If  it  becomes  a  pronounced  sjninptom  in 
chloroform  narcosis,  the  patient  is  usually  beyond  hope  of  resuscitation. 
As  long  as  the  heart's  action  is  sufficient  to  carry  the  blood-current  to 
the  important  cerebral  centers  an  extreme  cyanosis  is  not  incompatible 
with  prompt  resuscitation.  No  anu)unt  of  foi-eing  of  ah-  into  the  lungs, 
however,  can  bring  al)out  this  result  if  the  carbon-dioxide  accumulation 
is  the  result  of  cardiac  failure. 

Ether  the  Anaesthetic  of  Choice. — We  must  be  forced  to  the  conclu- 
sion, in  making  selection  of  an  angesthetic,  that  ether,  where  it  can  be 
employed,  is  the  anaesthetic  of  choice.  Since  Wimderlich  has  shown  that 
the  innnunity  from  renal  sequelae  formerly  supposed  to  exist  in  chloro- 
form narcosis  has  no  foundation  in  fact,  the  last  argument  in  favor  of 
the  employment  of  cldoroform  in  place  of  ether,  when  the  latter  is  not 
positively  coutraindicated — as,  for  instance,  by  actually  existing  pulmo- 
nary conditions  or  in  intracranial  operations,  in  which  class  of  cases  ether 
.seems  to  increase,  while  chloroform  decreases,  the  cerebral  congestion; 
and  in  certain  operations  about  the  mouth  and  face  where  the  galvano- 
or  thermocautery  must  be  used  or  the  mask  freqiiently  removed  in  the 
progTess  of  the  work — falls  to  the  ground,  when  statistics  shoMing  the 
unquestioned  safety  of  this  anaesthetic  agent  as  compared  with  chloro- 
form are  considered. 

A  collection  of  yearly  reports*  of  narcosis  covering  C2  reports,  mak- 
ing a  total  of  61,520  cases,  shows,  after  the  deduction  of  11,404  cases 
of  nitrous-oxide  anaesthesia,  that  there  were  11  deaths  in  the  remaining 
50,062,  or  one  in  4551  cases. 

The  number  of  cases  of  amrsthesia  collected  during  the  past  three 
years  amounts  to  101,800,  in  which  number  there  were  52  fatal  cases,  or 
one  death  in  8111  cases.  Of  133,729  cases  of  chloroform  anaesthesia 
there  were  40  deaths,  or  one  in  2907  cases.  In  14,040  cases  of  ether  nar- 
cosis there  was  not  a  single  death.  Of  mixtures  of  chloroform  and  ether 
there  were  4118  cases,  with  one  fatal  case.  Mixtures  of  chloroform,  ether, 
and  alcohol  (BiUi-oth's)  show  in  3440  cases  no  fatahty.     In  4555  cases  of 

*  Gurlt,  "  Beriehterstattung  liber  die  Sammelforschung  zur  Xarkotisu'ungsstatis- 
iik,"  Cciitnilblattfiir  Chmmjlc,  No.  30,  1893. 


602  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

broruide-of-etliyl  anesthesia  there  occurred  one  death.  Of  597  cases  of 
pental  anesthesia  3  were  fatal. 

To  sum  u]3.  therefore,  it  may  be  said  that  ever}"  patient  to  whom  an 
anaesthetic  is  administered  takes  thereby  some  risk,  but  that  this  risk  is 
less  in  ether  than  in  chloroform  narcosis.  Each  possesses  especial  advant- 
ages, but  those  claimed  for  chloroform  relate  chiefly  to  convenience, 
while  those  claimed  for  ether  relate  to  comparative  safety.  The  warn- 
ing signals  of  approaching  danger  in  ether  can  be  recognized  before  the 
l^atieut  is  beyond  recall ;  in  chloroform  he  is  frequently  already  within 
the  valley  of  the  shadow  of  death  before  the  antesthetizer  is  aware  that 
anything  is  wi-ong.  The  sm-geon,  therefore,  who  at  the  present  day 
selects  chloroform  as  the  anaesthetic  of  choice  would  do  well  to  fortify 
himself  with  facts  to  show  that  ether  is  contraindicated  in  the  particu- 
lar case ;  otherwise  the  accusation  may  be  made  that  an  unnecessary  risk 
was  assmued  in  emplojdng  chloroform  rather  than  ether,  the  patient  dying 
from  indul»ital;)le  chloroform  narcosis. 

More  skill  is  required  to  produce  ether  narcosis  than  chloroform  nar- 
cosis ;  more  skill  is  required,  also,  to  prevent  the  patient  fi*om  d\dng  from 
chloroform  than  from  ether.  An  indifferently  skillful  anaesthetizer  can 
easil}'  kill  a  patient  with  chloroform,  but  he  will  not  be  able  to  anaesthe- 
tize pro2:)erly  with  ether,  much  less  destroy  the  patient  without  some  warn- 
ing which  the  operator  himself  would  be  likely  to  observe.  "With  blood 
before  him  of  a  healthy  hue,  and  iho.  rh3"thm  of  regular  and  full  i-espirn- 
tions  in  his  ears,  the  latter  will  feel  safe  as  he  proceeds  in  his  work,  if 
ether  is  used.  Either  of  these  failing,-  a  word  of  caution  to  the  anaesthe- 
tizer  suffices  to  correct  the  undesirable  condition.  But  if  chloroform  is 
employed  the  experienced  oj^erator  knov/s  only  too  well  that  the  dark 
blood  and  absence  of  respiration  mean  that  the  heart  has  failed  in  its 
action,  perhaps  for  several  seconds  or  a  considerable  fraction  of  a  minute, 
before  the  dark  blood  and  failing  respiration  occurred,  and  from  this  time 
on  the  most  vigorous  efforts  must  be  made,  with  the  chances  greatty 
against  liim,  to  rescue  the  patient  from  death. 

Failure  to  Produce  Ansesthesia. — Occasionally  it  occurs  that  the 
attempt  to  etherize  a  patient  fails,  and  chloroform  is  substituted.  It  is 
more  than  probable  that  in  the  great  majority  of  cases  the  fault  lies  with 
the  anesthetizer,  and  not  with  the  j)atient  or  the  anaesthetic.  In  the  rare 
instances  in  which,  either  fi'om  the  extraordinarily  excited  condition  of 
the  patient,  or  the  occurrence  of  convulsive  or  even  tetanic  respu*atory 
movements,  there  is  a  failure  to  anaesthetize  referable  to  the  agent 
selected,  it  will  l:)e  found  that  the  patient  has  been  in  the  habit  of 
indulging  largely  in  alcoholic  stimulants.  A  change  to  chloroform  is 
here  indicated,  the  ether,  however,  being  resumed  when  narcosis  has 
been  established. 

Protection  of  the  Patient's  Face. — Complaints  of  negligence  may  be 
made  where  the  antesthetizer  fails  to  protect  the  jDatient's  face  from  con- 
tact with  the  anaesthetic  by  the  application  of  some  unctuous  material. 
Vaseline  answers  the  pm*pose  very  well  and  is  usually  employed.  Move- 
ments of  the  patient's  head  may  lead  to  the  accidental  entrance  of  ether 
or  chlorofonn  into  the  patient's  ej'es,  but  beyond  the  temporary  burning 
sensation  no  harm  usually  results  from  this.  It  should  be  provided 
against  by  placing  a  folded  towel  or  napkin  over  the  eyes. 


SVEGJCAL    MALl'UACriCE.  003 

Hydrobromic  ether  (bromide  of  ethyl)  Las  been  employed  to  some 
extent  tor  short  operations.  It  would  seem,  however,  that  this  aj^ent  is 
not  altogether  free  from  danger.*  From  5  to  10  grams  usually  suffiee 
for  complete  nareosis,  altliorigh  from  15  to  20  grams  may  be  used. 
In  one  case  40  and  in  another  -lO  grams  were  employed  with  fatal 
results  in  healthy  [)ersons.  It  is  a  dangerous  agent  to  employ  for  long 
operations,  profound  narcosis  leading  to  destruction  of  the  blood-coi-- 
puscles,  with  ))]oody  diarrha^a.  It  is  particularly  contraindicated  in 
anaemic  and  hysterical  women.  In  one  instance  of  this  kind  7.5  grams 
proved  fatal.  There  was  no  cyanosis,  but  the  respirations  failed  com- 
pletely, only  two  ineffectual  respiratory  efforts  being  made  after  narcosis 
was  established,  when  death  took  place.  In  Billroth's  clinic  400  anais- 
thetizations  were  made  with  bromide  of  ethyl;  in  one  case  a  fatal  result 
followed  the  sudden  elevation  of  the  patient  to  the  upright  position  for 
the  purposes  of  the  dressing.  In  this  case  cyanosis  was  observed  after 
some  seconds.  Tln-ee  minutes  after  the  esta])lishment  of  the  narcosis 
both  heart  and  i'esi)iration  had  failed.  The  post-mortem  showed  degen- 
erative changes  in  both  the  heart  and  renal  organs. 

It  is  now  generally  agreed  that  bromide  of  ethyl  is  less  dangerous 
than  chloroform,  but  that  wlide  it  possesses  some  advantages  as  to  con- 
venience, etc. — i)atients  coming  out  from  under  its  influence  very  much 
as  from  nitrous  oxide  or  laughing-gas — ^Tt  it  must  be  used  cautiously  as 
regards  the  quantity  employed.  The  stage  of  excitement  occurring  in 
connection  with  its  use  corresponds  closely  to  the  amount  used.  -The 
quantity  to  be  used  in  a  given  ease  is  poured  upon  a  cone  similar  to  that 
used  for  ether  and  covered  with  a  napkin. 

Rental  has  recently  been  introduced  as  an  ana?stlietic  agent.  Experi- 
ence with  it  has  been  thus  far  too  limited  to  admit  of  any  definite  opinion 
as  to  its  merits.  The  stage  of  excitement  is  said  to  be  very  short ; 
in  alcoholics,  however,  it  may  be  longer.  From  10  to  20  grams  are 
needed.  The  effect  is  said  not  to  be  unpleasant,  and  j^atients  do  not 
straggle  against  its  administration  as  with  other  anesthetics.  Sensil)il- 
ity  is  abolished  after  al)out  50  seconds,  and  the  stage  of  deep  analgesia 
is  reached  after  from  10  to  20  seconds  longer,  this  lasting  for  a  further 
50  seconds.  The  vapor  of  pental  is  easily  inflannnable,  and  the  same 
precautions  are  I'equisite  in  this  respect  as  during  the  administration  of 
ether.  The  patient  conies  out  from  under  its  influence  slowly.  Bronchial 
and  cardiac  affections  contraindicate  its  use.  A  j)eculiar  odor,  compara- 
ble to  that  of  asafetida,  pervades  the  room  after  its  use. 

Nitrous  Oxide. — Probably  the  safest  of  all  general  anaesthetics  is 
nitrogen  monoxide,  or  laughing-gas.  Its  use  is  greatly  restricted,  how- 
ever, by  the  fact  that  under  ordinary  circumstances  an  anaesthetic  effect 
of  but  short  duration  is  ol)tained,  although  Dr.  G.  W.  Brush,  of  Brooklyn, 
kept  a  patient,  upon  whom  the  writer  performed  a  laryngectomy  for  car- 
cinoma of  the  larynx,  under  its  influence  for  an  hour  and  forty  minutes.t 
Special  skill,  how^ever,  arising  from  a  long  experience  with  the  agent 
is  necessary  in  order  to  successfully  accomplish  such  a  I'csult.  Bert's 
method  involves  the  use  of  a  speciall}^  constructed  inhalation  chamber, 

*  MiinchcH.  Medic.  Wochcnsvhrift,  No.  15,  1890,  p.  267;  1891,  p.  5-4-4. 
t  American  Journal  of  the  Medical  Sciences,  October,  1889. 


604  ^   SYSTEM  OF  LEGAL  MEDICIXE. 

and  is  not  applicable  for  general  nse.    It  would  ajDpear  that  this  chamber 
is  not  at  all  necessary  for  the  purpose. 

Matters  in  Defense  in  Cases  of  Fatal  Narcosis. — The  dif&cnlties  in 
the  way  of  exactly  regulating  the  dose,  because  of  the  fact  that  all  gen- 
eral anfesthetics  are  exliibited  in  the  form  of  gas  or  vapor,  has  not  been 
overcome  by  any  of  the  so-called  safe  inhalation  apparatus  introduced 
for  this  puipose.  And  even  if  this  were  not  true  tlie  maximum  dose  for 
anaesthetic  agents  has  not  as  yet  been  estal)lished,  as  in  the  case  of  other 
powerful  drugs.  The  quantity  to  be  employed  in  any  given  case,  there- 
fore, must  depend  entu'ely  upon  the  surgeon's  subjective  judgment. 
What  is  more  than  all  other  things  necessary,  therefore,  is  that  the  sur- 
geon must  be  familiar  with  the  particular  agent  which  he  is  using,  and, 
especially  in  the  case  of  chloroform,  Tsith  the  deteriorations  which  this 
agent  is  subjected  to  when  kej)t  for  a  long  time  and  exposed  to  influ- 
ences, such  as  sunlight,  that  tend  to  alter  its  physical  qualities.  For 
such  changes  occm-ring  prior  to  the  chloroform  coming  into  the  hands 
of  the  surgeon  the  manufactui-er  or  dealer  is  to  be  held  responsible. 
He  must  lLk;e^\dse  be  familiar  with  and  have  at  hand  approved  means  of 
resuscitation,  as  well  as  di'ugs  of  an  antidotal  character,  such  as  strych- 
nia, tinctui-e  of  digitalis,  amyl  nitrite,  etc.,  to  administer  should  danger 
thi'eaten  the  patient.  With  these  conditions  fulfilled,  and  no  easily  dem- 
onstrable conditions  present  to  contraindieate  its  employment,  general  an- 
aesthesia may  be  established  even  for  the  performance  of  unimportant 
or  shght  operations.  The  omission  to  at  least  auscult  the  patient's 
chest  beforehand  would  be  considered  culpable  negligence,  even  when 
such  auscultation,  if  employed,  has  demonstrated  the  presence  of  a  heart 
mui'mui*,  in  a  case  in  which  it  is  absolutely  necessaiy  that  the  anaes- 
thetization  be  proceeded  vnth.  The  information  acquired,  although  per- 
haps it  would  not  prevent  the  use  of  the  anfesthetic,  would  tend  to  in- 
duce a  measure  of  watchfulness  and  caution  which,  it  might  be  claimed, 
would  not  otherwise  be  employed.  Examination  of  the  chest  organs, 
however,  does  not  always  afford  ti'ustworthy  data,  but  this  does  not  ex- 
cuse the  omission  of  this  precaution,  except  in  the  face  of  grave  emer- 
gencies. On  the  other  hand,  as  before  stated,  the  indubitable  evidences 
of  existing  disease,  the  circumstances  of  the  case  requiring  the  use  of  the 
anaesthetic,  may  permit  this  within  proper  limits,  and  with  the  usually 
employed  restoratives  at  hand.  It  will  usualh^  be  sufficient  for  the  sur- 
geon's protection  (1)  that  the  use  of  the  anfesthetic  was  necessary;  (2) 
that  the  agent  employed  was  adapted  to  the  particuh^r  case ;  (3)  that  a 
watchfid  care  was  exercised  during  the  administration  ;  (4)  that  the  usual 
restoratives  were  at  hand,  and  that  these  were  intelligently  applied  if 
they  were  requii'ed. 

SPECIAL  OR  REGIONAL  CONSIDERATIONS. 

In  re^dewing  the  accidental  complications  and  unfortunate  sequelae 
which  may  occur  in  surgical  ojDerations  and  affections,  it  is  to  be  observed 
that  there  is  scarcely  any  jDrocedure  that  may  not  lead,  either  from  indi- 
vidual carelessness  or  pure  accident,  to  misfortune.  It  is  intended  in 
this  connection,  however,  to  only  call  attention  to  some  of  the  more 
prominent  accidents  in  which  there  may  be  a  question  as  to  the  avoida- 
bility  or  otherwise  of  the  unfortunate  termination. 


SURGICAL   MALPRACTICE.  GOo 

Opening  an  Abscess. — Even  opening  an  abscess  has  been  the  occasion 
of  accidentally  woiindino-  an  inii>()]-tant  vessel.  Anenrisins  have  been 
mistaken  for  abscesses  and  opened  with  fatal  resnlts  fi-oni  henion-liag-e. 

Venesection. — This  operation  is  now  rarely  performed,  but  this  very 
fact  tends  to  lessen  our  estimate  of  the  importance  of  carrying  out  the 
j^rocedure  in  a  proper  manner.  The  median  cephalic  vein,  selected  for 
the  purpose,  is  sojuetimes  perforated  completely,  and  the  adjacent  artery 
is  injured  as  well.  The  artery  should  be  a(!curately  located  before 
placing  the  cojistricting  band  upon  the  arm.  The  surgeon  recognizes  the 
■occurrence  of  this  accident  l)y  the  simultaneous  steady  flow  of  dark 
venous  blood  and  the  pulsating  stream  of  bright  arterial  blood.  If  he 
bears  in  mind  the  fact  that  the  remote  injurious  effects  of  this  accident 
relate  mainly  to  the  resulting  communication  which  is  established  be- 
tween the  artery  and  the  vein,  and  takes  immediate  steps  to  prevent  this 
by  occluding  the  artery  by  means  of  a  graduated  compress  applied  to  it 
at  a  point  central  to  the  place  of  injury,  in  a  large  majority  of  cases  no 
permanent  harm  will  result. 

Embolism  from  Injection  of  Vascular  Tumors,  Varices,  etc. — At- 
tempts to  obliterate  vasculai'  tumoi's  and  varices  l)y  the  injection  of  cer- 
tain substances,  such  as  ferric  chloride,  carbolic  acid,  etc.,  have  been  fol- 
lowed by  rapidly  fatal  results.  Usually  an  elastic  bandage  is  placed 
above  and  below  the  point  of  injection  as  a  precautionary  measure.  The 
object  of  the  injection  is  to  produce  an  obliteration  of  the  enlarged  ves- 
sels by  coagulating  the  blood.  The  premature  removal  of  one  of  the 
bandages,  particularly  that  one  between  the  seat  of  coagulation  and  the 
heart,  has  resulted  in  the  occurrence  of  coagulation  in  the  vessels  T\dthin 
the  thorax,  and  rapid  death. 

Aneurism. — Aneurism  may  at  times  present  the  most  difficult  prob- 
lem in  the  art  of  diagnosis.  This  is  due  to  the  fact  that  the  disease  is 
mai'ked  by  varying  conditions  and  instability  of  symptoms,  as  a  result 
of  the  different  varieties  and  pai-ticular  stages  of  each  variety,  as  well  as 
to  the  fact  that  the  contents  may  be  entirely  fluid,  semi-fluid,  or  nearly  or 
quite  solid. 

Any  or  all  of  the  symptoms  may  be  misleading  and  bring  the  surgeon 
into  disrepute  because  of  failure  to  recognize  an  aneurism  when  present,  or 
of  ndstaking  another  form  of  tumor  for  aneurism  and  instituting  danger- 
ous measures  of  treatment,  such  as  incision,  ligature  of  the  main  vessel 
of  an  extremity,  the  application  of  continuous  pressure,  etc.  For  instance  : 
•(«)  every  tumor  situated  in  the  course  of  an  artery  is  not  an  aneurism ; 
(&)  ])ulsation  nuiy  be  absent  when  an  aneurism  is  present,  and  expansive 
pulsation  nuiy  be  present  in  an  abscess  surrounding  an  artery ;  (c)  the 
pulsation  may  cease  in  a  tumor  or  swelling  situated  upon  oi-  in  the  neigh- 
t)orliood  of  an  artery  when  compression  is  made  upon  the  cardiac  side, 
on  the  one  hand,  while,  on  the  other,  subsidence  of  the  swelling  may 
not  occur  and  yet  an  aneurism  be  present ;  {d)  a  bruit  mny  be  absent  in 
aneurism  and  be  present  in  the  case  of  an  abscess  or  tumor  surrounding 
or  situated  upon  a  vessel;  [e)  even  exploratory  puncture  may  residt  in 
the  withdrawal  of  bright  arterial  blood  in  several  vai'ieties  of  tumor,  and 
in  aneurism  this  means  may  fail  to  give  exit  to  blood. 

The  history  of  the  case  is  of  great  value,  and  errors  in  diagnosis  arise 
most  frequently  from  failure  on  the  part  of  the  surgeon  to  carefully  in- 
quire into  the  early  symptoms,  the  length  of  time  of  their  existence,  etc. 


606  ^   SYSTEM   OF  LEGAL  MEDICIXE. 

Under  these  circumstances  the  practitioner  may  be  justly  regarded  as- 
ha\dng  been  culj^ably  negligent.  The  most  eminent  surgeons,  however, 
have  failed  to  make  a  correct  diagnosis,  even  when  the  history  has  been 
taken  into  account,  the  symptoms  methodically  studied,  and  the  value 
of  the  latter  carefully  weighed  in  the  particidar  case. 

Many  instances  are  recorded  in  which  an  aneurism  existed  when  the 
histoiy  and  symptoms  indicated  an  abscess.  (Sir  Charles  Bell,  Dupuy- 
tren,  Cooper.*)  Again,  the  early  history  may  indicate  an  aneurism,  all  the 
symptoms  pointing  to  the  existence  of  an  abscess.  Finally,  an  aneurism 
and  abscess  may  coexist.  The  former  may  follow  and  be  dependent  upon 
the  latter,  in  which  case  the  early  history  and  sjonptoms  point  to  abscess, 
while  the  later  ones  indicate  the  existence  of  an  aneurism.  Or  the  aneu- 
rism may  occui-  first,  followed  by  inflammation  in  the  connective  tissue 
about  the  tumor,  terminating  in  suppuration.  (Deschamps.)  Under  these 
circumstances  the  early  histoiy  is  that  of  aneuiism,  the  later  symptoms 
those  of  abscess.  The  symptoms  of  aneurism,  however,  continue  to  be 
the  more  i3rominent,  as  a  rule,  and  errors  of  diagnosis  are  not  necessarily 
of  a  serious  character,  for  the  reason  that  the  careful  and  intelligent  sur- 
geon will  always  take  into  account  the  symptom  of  pulsation  and  apply 
such  scientific  tests  as  may  serve  to  clear  up  the  diagnosis.  If  he  is 
finally  impelled  to  incise  the  swelling  he  will  do  so  with  such  precaution- 
ary measures  as  will  permit  him  to  either  retrace  his  steps  before  great 
harm  has  been  done,  or  operate  for  the  cm'e  of  the  aneurism. 

Puncturing  an  aneurism  by  mistake  for  an  abscess  has  not  infrequently 
occurred.  These  are  among  the  most  serious  of  the  mishaps  of  surgical 
practice,  and  if  expansive  pidsation  is  present,  they  are  certainly  ajnong 
the  most  inexcusable.  Two  such  cases  came  under  the  care  of  Mr. 
Erichsen,  and  both  succumbed  to  the  operative  procedure  iustituted  to 
correct  the  mistakes  of  the  practitioners  who  were  guilty  of  the  errors. 
In  a  third  case  there  was  some  excuse  for  the  error  for  the  reason  that 
the  symptoms  of  popliteal  aneurism  were  not  weU  defined.  {Lancpf, 
1858.) 

The  error  of  mistaking  an  abscess  for  an  aneurism  in  a  locality  where, 
if  the  latter  existed,  it  woidd  be  almost  necessarily  iucui*able,  while  an 
abscess  would  imperatively  demand  operative  interference,  is  sometimes 
made.     The  following  case  is  offered  in  illustration : 

Miss  B.,  of  Rockville  Center,  L.  I.,  aged  twenty-two  years,  a  school- 
teacher by  occupation,  was  referred  to  me  by  her  attending  physician 
for  diagnosis.  She  had  noticed  a  tender  spot  over  the  third  rib  upon 
the  left  side  for  about  two  months,  following  which  swelling  occuri-ed,. 
and  fever  of  an  intermittent  t^^pe.  There  had  been  no  symptoms  of  car- 
diac disturbance,  no  dyspnoea,  nor  had  the  present  tumor,  the  size  of  a 
fist,  been  preceded  in  its  development  by  the  usual  extreme  pains  incident 
to  the  progi-ess,  in  an  outward  direction,  of  thoracic  aneurism.  Before 
presenting  to  me  the  letter  of  introduction  from  her  physician  she  visited 
some  friends  in  the  city,  who  persuaded  her  to  consult  two  other  sur- 
geons. The  first  of  these  introduced  an  exploring  needle  and  withdrew 
a  small  quantity  of  blood.  She  then  consulted  the  other  surgeon,  who 
pronounced  the  case  to  be  one  of  aneurism  and  strongly  advised  her  not 
to  permit,  under  any  circumstances,  any  surgeon  to  intei-fere  with  the 

*  Stephen  Smith,  American  Journal  of  tlic  Medical  Sciences,  April,  1873. 


SURGICAL    MAI.m.K  IK  !■:.  (JOJ 

tumor,  but  to  i)roeeed  at  once  to  lier  parents'  home  in  western  New  York, 
there  to  await  lier  inevital)le  fate. 

Upon  examining-  the  tumor  I  found  it  to  be  the  site  of  a  well-marked 
but  not  expansive  pulsation.  There  was  no  bruit  present.  The  skin 
over  the  tumor  was  reddened  and  tender.  The  age  of  the  patient,  the 
history  of  the  development  of  the  tunu)r,  and  the  accompanying  feljrile 
symptoms  all  impelled  me  to  the  diagnosis  of  abscess,  and  I  proposed  to 
her  to  enter  the  Methodist  Episcopal  Hospital  for  exploration  at  least. 
So  impressed  was  she,  however,  by  the  warning  of  the  gentleman  who 
had  pronounced  the  case  to  be  one  of  aneurism  that  she  decided  to  go 
home  to  die. 

Six  months  later  I  learned  from  the  physician  who  had  referred  her 
to  me  that  the  local  practitioner  who  had  her  in  charge  at  her  parents' 
home  had  become  convinced  that  she  was  suffering  from  an  abscess,  and 
had  persuaded  her  to  permit  a  surgeon  from  a  neighboring  city  to  oper- 
ate. More  than  a  quart  of  pus  was  evacuated,  and  extensive  necrosis  of 
the  chest  wall  discovered.     No  aneurism  was  present. 

Gunshot  Injuries. — The  greatest  possible  diversity  will  be  found  to 
exist  in  different  cases  of  gunshot  injuries.  Differences  in  velocity,  pro- 
jectile force,  angle,  articles  perforated  before  the  l^all  reaches  the  body, 
and  tissues  traversed,  all  have  an  influence  in  determining  the  character 
of  the  injury.  A  ball  may  strike  a  bone,  giance  off,  and  bury  itself  into 
the  siuTounding  structures.  Although  the  injuiy  to  the  soft  pai-ts,  to- 
gether with  its  sequela',  will  occupy  the  attention  of  the  siu'geou,  the  fact 
is  not  to  be  lost  sight  of  that  certain  changes  may  take  place  in  the  bone 
itself,  such,  for  instance,  as  infectious  periostitis  and  ostitis,  the  infec- 
tion finding  its  way  into  these  strnctures  eithei*  dii-ectly  from  foreign  sub- 
stances carried  in  with  the  ball  itself,  or  from  suppurative  pi'ocesses  ha^'- 
ing  their  point  of  commencement  in  the  soft  parts  aud  subse(pieutly 
extending  to  the  bony  structures. 

The  immediate  complications  most  to  be  dreaded  iu  gunshot  injuries 
relate  to  important  vessels  and  nerves.  While  hemorrhage  from  vessels 
in  the  torn  and  lacerated  muscular  structures  may  be  at  first  profuse, 
the  irritability  of  the  latter,  producing  involuntary  muscular  contrac- 
tions, together  with  the  tendency  on  the  part  of  the  In-uised  and  irregu- 
larly divided  walls  of  the  vessels  to  favor  coagulation,  lead  to  i-ather 
prompt  arrest  of  the  bleeding.  But  the  surgeon  should  not  overlook  the 
possibility  of  a  contusion  of  the  wall  of  a  large  vessel  having  occurred, 
which  may  lead  in  the  coiu-se  of  a  week  or  ten  days  to  a  most  pi-of  use 
and  dangerous  secondary  hemorrhage.  Failure  to  provide  against  the 
possibility  of  this  accident  may  become  a  source  of  reproach  to  the  attend- 
ant, or  even  become  the  basis  for  a  suit  for  malpractice. 

More  or  less  damage  to  important  nerve  structm-es  may  occtu*  in  gun- 
shot injiiries,  which  in  the  excitement  of  the  moment  maybe  overlooked. 
Such  iujuries  are  most  frequently  fouud  where  the  extremities  are  in- 
volved, either  from  the  direct  blow  of  the  ball,  by  force  transmitted 
through  the  medium  of  a  fragment  of  bone,  or  by  muscuhu*  contraction 
forcing  pointed  or  sharp-edged  spicuhi?  against  the  nerve  trunk.  Injury 
to  important  nerves,  when  sutficiently  severe,  leads  at  once  to  complete 
paralysis  of  their  peripheral  distribution.  In  addition,  injury  to  lar-ge 
nerves  greatly  increases  the  surgical  shock,  which  may  become  so  pro- 
found as  to  briuii;  about  fatal  inhibition  of  vital  functions. 


<50S  ^   SYSTEM  OF  LEGAL  MEDICINE. 

If  a  fracture  has  takeu  place  as  tlie  result  of  a  gunshot  injury,  the 
bone  may  be  completely  shattered,  and  the  residting  deformity  will  be 
at  once  apparent.  But  if  a  portion  of  bone  has  been  simply  carried 
away  by  the  ball  in  its  passage,  nothing  short  of  an  exploration,  and  this 
jjreferably  with  the  surgeon's  finger,  properly  cleansed  and  disinfected 
for  the  purpose,  "v\dll  suffice  in  estabhshing  the  diagnosis.  Neglect  of 
this  in  the  case  of  a  gunshot  wound  of  an  extremity,  or  in  fact  in  all 
portions  of  the  body,  with  the  exception  of  penetrating  wounds  of  the 
great  cavities,  may  lead  to  error  as  to  the  extent  of  the  injury  inflicted. 

The  surgeon's  fixst  investigation  will  be  directed  as  to  whether  the 
missile  is  still  located  in  the  tissues  or  not.  He  will  therefore  seek  to 
ascertain  if  there  is  present  a  wound  of  exit  as  well  as  one  of  entrance. 
Several  fallacies  may  enter  at  this  point,  against  which  the  surgeon  must 
be  on  his  guard.  The  existence  of  but  one  wound  does  not  always  de- 
termine the  Cjuestion  affii'matively,  any  more  than  the  presence  of  two 
wounds  can  decide  it  negatively.  In  the  first  instance  the  ball  may  have 
di'opped  out  in  transporting  the  patient,  or  may  have  been  di'agged  out 
in  undi'essing  the  patient  by  a  portion  of  clothing  which  was  carried  into 
the  wound  with  the  baU.  An  accurate  inspection  of  the  surroundings, 
including  the  clothing  of  the  patient,  should  therefore  be  made,  in  order 
that  needless  injury  be  not  inflicted  in  an  unnecessary  probing  of  the 
woimd  in  searching  for  the  ball.  Failing  to  thus  find  the  ball,  attention 
should  be  directed  to  the  possibility  of  the  baU  being  superficially  located. 
To  this  end  every  portion  of  the  adjacent  and  even  remote  parts  which 
<^ould  have  possibly  been  in  the  line  of  the  projectile  is  to  be  carefully 
examined.  Next,  the  possibility  of  the  ball  having  been  deviated  from 
its  coiu'se  by  contact  \\dth  bone  or  by  dense  planes  of  intermuscular  apo- 
neurotic structures  after  its  force  was  partially  spent  should  be  taken 
into  account.  Carefiil  palpation  should  be  performed,  in  order  to  be 
certain  that  the  missile  does  not  lie  directly  beneath  the  skin  at  some 
point  easily  accessible  for  piu'poses  of  removal,  before  instituting  a  formal 
and  perhaps  dangerous  exploration  or  extensive  dissection  for  its  removal. 
All  suspicious  elevations  of  the  skin  should  be  carefully  examined  by  the 
surgeon,  and  failing  to  thus  locate  the  bullet  the  question  as  to  whether 
fmther  search  should  be  instituted  or  not  should  be  discussed.  In  eases 
in  which  two  wounds  exist,  one  representing  the  point  of  entry  and  the 
other  that  at  which  the  ball  left  the  body,  there  may  still  exist  a  doubt 
as  to  the  absence  or  presence  of  the  missile,  or  at  least  a  portion  thereof, 
in  the  tissues.  The  wisdom  of  examining  the  clothing  is  here  again 
manifest.  A  ball  may  have  been  split  or  divided  \>y  contact  with  a  sharp 
bony  edge,  and  in  its  fmther  passage  a  portion  may  have  left  the  body 
by  the  wound  of  exit,  while  the  rest  still  remained  lodged  in  the  tissues. 
The  portion  which  escaped  may  sometimes  be  found  in  the  clothing,  and, 
its  di\dded  condition  being  apparent,  form  the  basis  for  further  search. 

The  justifiability  of  risking  injury  to  important  parts  in  attempting 
to  remove  the  ball,  after  having  located  the  latter,  should  be  decided  only 
with  reference  to  the  patient's  own  interests.  The  dangers  to  be  feared 
from  its  presence  in  the  tissues  should  be  weighed  against  the  risks  at- 
tending its  removal.  It  is  a  grave  error  to  mutilate  a  limb  or  to  invade 
one  of  the  gi'eat  ca^nties  of  the  body  in  the  search  for  or  removal  of 
a  ball  whose  presence  would,  in  all  probability,  do  less  harm  than  the 
operative  procediu-e  itself.     Wliere,  however,  as  for  instance  in  the  peri- 


SURGICAL   MALPRACTICE.  GOD 

toneal  cavity,  serious  complications  may  arise — not  necessarily  from  the 
continued  presence  of  the  ball,  but  rather  from  damage  done  to  impor- 
tant structui'es  by  the  es(uipe  of  fecal  matter  from  the  intestinal  canal, 
liemorrluige,  etc. — explorative  operative  procedures  are  not  only  war- 
ranted but  imperatively  demanded.  Under  these  circumstances  merely 
tentative  measiu'es  such  as  probing  are  not  only  contraindicated,  but 
are  apt  to  do  more  harm  than  good.  The  passage  of  a  probe  cannot  give 
trustworthy  information  as  to  whether  intestine  has  been  wounded  or 
hemorrhage  is  going  on  in  the  alidominal  cavity,  any  more  than  it  can 
determine  the  probiible  course  of  the  ball  beyond  its  passage  through 
the  abdominal  parietes.  On  the  other  hand,  probing  may  carry  infec- 
tion Jinto  the  peritoneal  cavity,  or,  if  it  chance  to  pass  into  a  perforation 
of  intestine,  may,  in  withdramng,  smear  fecal  matter  ui)on  the  peritoneal 
sui'faces. 

In  grmshot  wounds  of  the  head  meddlesome  surgery  is  always  bad 
surgery.  While  tui'uing  back  a  flap  of  the  scalp  in  order  to  determine 
whether  or  not  the  ball  has  entered  the  cavity  of  the  skull,  and  the  inci- 
dental removal  of  accessible  spiculte  of  bone  which  have  been  driven 
into  the  cerebral  tissues,  are  proper  procedures  in  selected  cases,  failure 
to  institute  further  interference  than  this  mil  never  bring  reproach  to 
the  surgeon.  Under  these  cii'cumstances  his  conservatism  will  be  com- 
mended by  his  professional  brethren.  Aimless  probing,  on  the  other 
hand,  will  be  almost  certain  to  inflict  further  damage. 


THE    HEAD   AXD   NECK. 

Atheroma  of  the  Scalp. — These  so-called  ''wens"  are  frequently  re- 
garded as  simple  affairs,  and  operated  upon  by  those  who  have  had  but 
slight  experience  in  surgical  operative  work.  While  the  operation  is 
usually  a  simple  one,  this  very  fact  sometimes  leads  to  a  neglect  of 
precautions  which  would  be  taken  in  more  serious  operations.  In  pre- 
antiseptic  times  many  of  these  cases  perished  fi'oni  erysipelatous  inflam- 
mation, to  which  the  region  of  the  face  and  scalp  seems  to  be  especially 
prone.  Patients,  especially  women,  mil  frequently  object  to  the  removal 
of  the  hair  necessar}^  to  a  complete  aseptic  course  of  technique,  and  the 
surgeon  wiU  be  inclined  to  listen  to  their  entreaties.  If  the  practitioner 
has  a  due  regard  for  the  patient's  best  interests  as  well  as  for  his  own 
reputation  he  Avill  insist  upon  the  necessary  steps  of  preparation,  or  de- 
cline the  responsibility  of  the  operation. 

Trephining. — This  operation  has  not  infrequently  been  performed 
with  the  expectation  of  finding  an  abscess  of  the  brain,  oi-  a  coagulum, 
when  neither  was  finind.  Exploratory  trephining  in  cases  diagnosticated 
as  hemorrhage  from  the  middle  meningeal  artery  is  followed,  even  in  the 
best  of  hands,  by  the  discovery  that  the  blood  is  fm*nished,  not  by  the 
artery,  but  hj  one  of  the  sinuses  of  the  dura  nmter. 

Operations  for  Harelip. — Few  realize  the  intrinsic  dangers  of  the 
operative  procedure  for  the  correction  of  this  congenital  deformity.  It 
is  estimated  that  fully  one  third  of  the  cases  submitted  to  the  operation 
die  (Nussbaum),  as  an  immediate  result  from  suifocation  consequent  u])ou 
the  enforced  closure  of  the  mouth.  Following  the  loss  of  considerable 
blood,  the  little  patients  easily  succumb  to  slight  causes.     The  infec- 


610  ^   SYSTEM  OF  LEGAL  2IEDICIXE. 

tion  of  a  sutiu'e  track,  due  to  the  negiect  of  asejDtie  precautions,  leads 
to  eiysipelatous  inflammation,  wliich.  in  its  turn  produces  pain  and  rest- 
lessness. Fear  of  failure  of  the  operation  leads  to  the  administration  of 
opium,  which  the  little  patients  bear  badlv  in  their  weakened  condition. 
Without  the  administration  of  opium  the  continued  acts  of  crpng-  lead 
to  straining  uijon  and  finally  the  tearing  out  of  the  sutui'es.  The  deformity 
is  thus  frecpiently  made  worse  than  at  first. 

The  cosmetic  result  in  cases  of  hareHp  is  frequently  unfavorable  even 
after  the  best-conducted  antisej^tic  procedui'es,  for  the  i-eason  that  the 
operator  does  not  fully  appreciate  the  necessity  of  a  decided  projection 
upon  the  vermilion  border  at  the  point  where  the  incision  terminates,  to 
allow  for  subsequent  contraction  of  the  cicatrix  when  perfectly  healed. 
This  contraction  may  go  on  for  a  long  time,  and  unless  the  precaution 
alluded  to  is  observed  an  unsightly  notch  will  appear  at  the  point  where, 
at  first,  the  Up  was  perfecth'  sjTnmetrical.  A  fiu'ther  unsighthness  fol- 
lowing the  operation  results  from  the  injudicious  removal  of  the  promi- 
nent intermaxillary  bone.  A  comparison  of  the  faces  of  two  persons 
operated  u]Don  in  early  life  for  harelip,  in  one  of  whom  the  intermaxillary 
bone  was  removed,  while  in  the  other  it  was  allowed  to  remain,  shows 
such  striking  differences  as  to  stamp  the  former  procedm-e  as  most  unjus- 
tifiable and  cruel. 

The  selection  of  the  proper  age  for  the  operation  is  of  importance. 
While  single  harelip  may  be  oj)erated  upon  at  ahnost  any  time,  in  double 
hareHp  it  is  better  to  po.stpone  the  operation  until  the  second  year  of  life. 

Cleft  Palate. — In  cleft-palate  operations  the  same  dangers  threaten 
the  child  as  in  harelip,  Imt  to  a  gTeater  degree.  Very  young  childi-en  do 
not  bear  the  loss  of  blood  at  all  well,  and  therefore  it  is  better  to  defer 
interference  until  they  arrive  at  an  age  when  they  can  undergo  the  neces- 
sarily extensive  operative  procedures  with  less  fear  of  an  immediately 
fatal  result.  The  mortahty  in  early  infancy  is  almost  fifty  percent.  The 
most  favorable  period  for  the  operation  so  far  as  danger  to  life  is  con- 
cerned is  at  the  fifth  year.  (Sehede.)  On  account  of  the  extent  to  which 
ui-anoplasty  interferes  with  the  development  of  the  arch  of  the  palate,  it 
may  be  postponed  until  the  period  of  the  second  dentition,  or  between 
the  tenth  and  twelfth  years.     (Ehrinann.) 

Failm'e  in  the  immediate  result  is  less  frequently  due  to  an  insuffi- 
ciency of  blood-suj)ply  from  injmy  to  the  arterial  branches  than  to  the 
fact  that  too  few  veins  are  present  in  the  pedicles  to  maintain  the  return- 
circulation.  The  cicatricial  tissue  left,  however,  after  the  mucoperios- 
teal  flaj^s  have  sloughed  away,  can  frequently  be  utilized  for  a  second 
operation. 

Failure  in  the  functional  result  is  more  frequent  and  important.  The 
voice  is  not  greatty,  if  at  all,  improved,  and  the  surgeon  is  frequently 
blamed  because  of  the  disappointment  in  this  respect  by  both  the  patient, 
when  old  enough  to  realize  the  extent  of  his  misfortune,  and  l)y  the 
fiiends.  In  undertaking  an  operation  of  this  kind  the  siu'geon  should 
bear  in  mind  that  a  congenital  cleft  in  the  palate  is  not  merely  a  .slit 
in  the  parts,  but  that  an  actual  deficiency  of  tissue  exists.  Hence  even 
after  a  most  skillfully  performed  operation  for  closure  of  the  cleft  the 
velum  still  remains  as  a  tight  curtain  stretched  across  between  the  oral 
and  pharyngeal  caAT.ties  and  the  posterior  nares,  which  is  too  short 
to  reach  the  posterior  pharpigeal  wall,  and  past  which  the  air  rushes 


SURGICAL  MALPRACTICE.  Gil 

from  the  pliaiynx  thrmig-h  the  posterior  nares ;  the  peculiar  nasal  twang 
is,  therefore,  still  present.  Wliile  certain  vocal  exercises  are  not  with- 
out value  in  obviating*  this,  a  perfect  production  of  normal  voice  and 
speech  has  probal)!}^  nev'er  l)eeii  produced  by  lu'anoplasty  and  staph}-lor- 
rhaphy. 

The  Teeth. — The  accidt^ntal  extraction  of  the  wrong  tooth  has  some- 
times brought  reproach  upon  the  operator.  This  occurs  moi-e  fre(|uently 
since  the  inti-oduction  of  iUUTesthetics.  The  patient  will  not  always  be  able 
to  point  out  the  tooth  which  is  at  faidt,  and  even  if  al)le  to  identifj^  it 
he  may  place  his  finger  upon  two  or  even  three  in  the  attempt  to  indicate 
the  one  which  causes  the  difficulty.  Again,  two  teeth  maj''  be  so  closel}- 
attached  as  to  make  it  impossilde  to  remove  one  without  the  other.  Luxa- 
tion of  the  lower  jaw  has  occurred  when  great  force  has  been  necessary 
in  the  extraction.  Fracture  of  the  jaw,  coiisideraljle  portions  of  the 
alveolar  process  being  brought  away  with  the  tooth,  has  been  the  basis 
of  malpractice  suits.  Such  accidents  will  occur  in  the  most  skillful  hands, 
but  if  the  mouth  be  carefully  kept  clean  and  septic  complications  avoided, 
the  patient  can  scarcely  have  been  sufficiently  damaged  to  warrant  a  suit. 
While  replacing  the  broken-off  part  may  sometimes  he  folk) wed  by  com- 
plete union,  yet  the  pressure  of  a  loose  and  perhaps  pointed  or  sharp- 
edged  piece  of  bone  in  the  oral  cavity  invites  dangers  from  irritation  of 
the  adjoining  cheek  and  tongue  which  far  outweigh  any  advantages  to 
be  derived  from  the  replacement  and  union  of  the  bone  itself. 

Hemoi'rhage  following  the  extraction  may  be  alarming,  and  requii'e 
the  employment  of  the  thermocautery  for  its  arrest. 

When  dentures  are  attached  to  the  patient's  own  teeth  the  latter  may 
become  worn  at  the  point  where  the  metal  clasps  are  applied,  with  the 
result  of  allowing  the  plate  and  artificial  teeth  to  fall  back  into  the 
pharynx  or  esophagus.  Cases  are  recorded  (Nussbaum)  in  which  a  dent- 
ure has  been  lodged  in  these  positions  for  months  without  giving  rise 
to  dangerous  consequences.  Under  these  cu-cumstances,  for  the  reason 
that  the  treatment  of  a  condition  shoidd  not  be  more  dangerous  than 
the  condition  itself,  surgeons  have  generally  not  ad\"ised  interference 
before  some  du*ect  indication  had  existed  for  this. 

Tonsilotomy. — Several  accidents  may  follow  this  apparently  simple 
operation,  for  which  the  surgeon  may  be  blamed.  The  shce  of  tonsil 
removed  has  fallen  upon  the  glottic  opening  and  caused  suffocation. 
With  the  modern  tonsil  guillotine  the  risks  of  this  accident  are  reduced 
to  a  minimum.  The  instrument  also  guards  against  injury  of  the  larger 
vessels,  which  may  occur  when  an  ordinary  scalpel  is  used.  The  presence 
of  a  calculus  in  the  tonsil  may  prevent  the  use  of  the  guillotine,  and 
even  break  it,  and  necessitate  the  use  of  the  scalpel  or  bistoury  to  dis- 
entangle the  broken  instrument,  as  well  as  to  remove  the  tonsil.  The 
surgeon  may  be  compelled  to  adopt  the  use  of  the  scalpel  by  force  of 
circumstances.  Hemorrhage  following  the  operation  of  tonsilotomy  has 
given  rise  to  great  anxiety,  as  regards  both  the  patient  and  the  surgeon's 
reputation.  Wliile  ligature  of  the  external  carotid  artery  has  been  re- 
sorted to  in  this  complication,  the  necessity  for  tliis  nuist  be  exceptional. 
The  application  of  the  thermocautery  or  pui'e  spirits  of  turpentine  is  fre- 
quently sufficient.  These  fading,  suturing  together  of  the  pillars  of  the 
fauces  over  the  bleeding  stump  of  the  tonsil  will  almost  certainly  arrest 
the  hemorrhage. 


(312  J.   STSTE^I  OF  LEGAL  MEDICINE. 

Retropharyngeal  Tumors. — lu  the  osteoplastic  resection  of  tlie 
upper  jaw  suggested  by  Laugeubeck  for  the  removal  of  retrophaiyugeal 
tumors,  portions  of  the  growth  mav  become  detached  from  the  remainder 
and  fall  upon  the  glottic  opening,  prodncing  death  by  suffocation. 

Catheterization  of  the  Eustachian  Tube. — Fatal  phlegmon  of  the 
neck  has  followed  attempts  at  catheterization  and  mflation  of  the  Eusta- 
chian tube,  the  au'  being  forced  into  the  cellular  tissue  of  the  neck. 

Mastoid  Disease. — In  cases  of  suppnrative  disease  of  the  middle  ear 
the  surgeon  who  fails  to  take  note  of  the  supervention  of  mastoid  dis- 
ease, when  such  well-marked  e^ddences  of  this  condition  are  present  as- 
are  furnished  b}'  the  occiu-rence  of  swelling  and  tenderness  over  the  mas- 
toid region,  commits  a  serious  error.  The  occurrence  of  gastric  irrita- 
tion in  these  cases  should  also  arouse  snspieion.  The  proximity  of  the 
cerebrum  to  the  labpinth,  only  a  thin  lamella  of  bone  intervening,  and 
the  dangers  of  infection  of  the  cerebellum  throngh  pldebitis  of  the  lateral 
sinus,  should  be  borne  in  mind.  It  is  not  a  serions  mistake  to  ti'ephine 
the  mastoid  process  and  not  find  pus ;  but  it  is  a  most  gTave  error  to  fail 
to  apply  such  a  comparatively  simple  procedure  in  cases  in  which  the 
patient's  life  depends  npon  its  performance. 

Injury  of  the  lateral  sinns  is  a  not  infreqnent  accident  in  trephining 
the  mastoid  process.  An  exceedingly  threatening  or  even  fatal  hemor- 
rhage may  follow.  In  performing  this  operation  the  sui'geon  should 
bear  in  mind  the  importance  of  not  carrying  the  perforation  of  the  bone,, 
or  the  clearing  out  of  the  abscess  ca^-ity  by  means  of  the  sharp  spoon,, 
too  gTcat  a  distance  fi'om  the  immediate  neighborhood  of  the  helix. 

Tracheotomy. — Several  accidents  may  occm-  in  the  com-se  of  a  trache- 
otomy. There  may  be  an  alarming  hemorrhage  fi*om  the  engorged  ves- 
sels in  the  neck.  The  o^^ening  of  the  trachea,  particularly  if  the  case  is 
an  nrgent  one,  need  not  be  delayed  until  this  has  been  arrested.  The 
application  of  a  few  hemostatic  forceps,  and  relief  of  the  dyspnoea  by  the 
introduction  of  the  cannula,  will  be  almost  always  followed  by  an  im- 
provement. 

The  trachea  may  elude  the  operator  and  the  esophagus  be  wounded,. 
or  the  latter  may  occur  from  transfixion  of  the  trachea,  a  tracheo-eso- 
phageal  fistula  becoming  established.  Or  the  trachea  may  be  opened 
upon  its  antero-lateral  or  even  its  lateral  snrface,  great  difficult}^  being- 
experienced  in  the  introduction  of  the  cannnla. 

These  difficulties  and  accidents  may  nsually  be  avoided  by  inserting- 
a  tenaculum  into  the  trachea  and  steadying  the  latter  while  the  incision 
into  the  anterior  wall  is  deliberately  made.  The  hold  which  the  tenacu- 
lum has  upon  the  trachea  should  not  lie  rehnquished  until  the  cannula 
is  in  position  and  all  hemorrhage  arrested. 

In  the  absence  of  the  surgeon  a  j)iece  of  false  membrane  may  become 
loosened  and  block  np  the  cannula.  Those  left  in  charge  of  the  patient 
must  be  instructed  under  these  circumstances  to  remove  the  cannula 
entirely,  rather  than  i-isk  the  delay  incident  to  efforts  at  clearing  its 
lumen.  If  the  loosened  piece  is  engaged  in  the  tube  it  will  probably 
come  out  with  it;  if  not,  the  opening  in  the  trachea  affords  a  larger 
exit  than  the  lumen  of  the  cannula. 

Thyroidectomy. — In  addition  to  the  dangers  of  the  operative  pro- 
cedm-e  itself — invohing  as  it  does  extensive  dissections  in  the  neighbor- 
hood of  important  vessels  and  nerves,  during  which  accidental  injuiy  to 


SilidlCAL    MAIJ'RACTWE.  G13 

tlieye  may  result  in  destruction  of  the  patient — and  those  arising  from 
sudden  bendin<?  of  a  trachea  which  has  become  thinned  and  flattened  l)y 
pressure  (s('al)l)ar(l  traclica),  in  a  (certain  propoi'tion  of  <uises  a  pecniliar 
cacliexia  (cjudiexiji  stnniii})rivai)  supervenes  in  a  few  weeks  oi-  iiiontlis. 
The  atfeetiou  is  ehanieterized  ])y  certain  psyehieal  and  pliy.sieal  (lisliirh- 
ances  whieli  correspond  very  closely  to  those  in  the  idiopathi(;  (condition 
known  as  uiyxedeina.  A  more  acute  form  is  known  ;is  tetany,  a  si)as- 
modic  affection  somewhat  resembling  tetanus,  but  in  which,  however,, 
there  is  no  underlying-  infection. 

Owing  to  the  frequent  occurrence  of  tlie  unfortunate  complications 
and  S(M{ueke  just  alhuhnl  to,  goitres  are  not  to  be  totally  removed.  Even 
when  the  vital  indications  are  present  for  operative  interference,  small 
portions  may  be  left  attached  to  the  trachea,  ov  even  but  one  lobe  re- 
moved. Cachexia  strumipriva  is  thus  avoided.  Experience  likewise 
teaches  that  the  removal  of  a  (;omparatively  small  portion  of  a  tlip'oid 
tumor  is  sometimes  followed  1)y  degenerative  changes  in  the  remainder.. 

Incisions  in  the  Neck  for  Suppurative  Conditions. — Fear  of  injur- 
ing the  larger  vessels  in  the  neck  frequently  impels  the  practitioner  to 
delay  opening  foci  of  suppuration  in  this  neighborliood,  such  delay 
resulting  in  serious  consequences.  This,  as  well  as  undue  risk  to  im- 
portant structures,  may  be  avoided  by  simply  incising  the  skin  and  tlien. 
completing  the  search  for  the  pus  cavity  with  a  blunt  dressing-forceps. 
The  track  thus  made  and  leading  to  the  purulent  collection  may  be 
dilated  sufficiently  by  spreading  the  blades  of  the  forceps  so  as  to  permit 
the  introduction  of  a  drainage-tube.  The  blunt  extremity  of  the  forceps 
will  not  injure  the  vessels  imder  ordinary  circumstances. 

Tumors  in  the  Region  of  the  Neck. — In  addition  to  the  accidents 
which  may  arise  in  the  coui'se  of  operations  for  the  removal  of  tumors  of 
the  neck  relating  to  injuries  of  the  nerves  and  vessels,  aspiration 
of  air  in  wounds  of  the  larger  vessels,  etc.,  the  surgeon  may  be  blamed 
for  the  needless  infliction  of  deforming  cicatrices  in  the  case  of  j^oung 
females.  Lines  of  incision  may  be  so  planned  as  to  tm-n  back  the  over- 
lying skin  without  bringing  the  resulting  cicatrix  into  prominence  and 
rendering  this  region  unsightly.  An  incision  with  beveled  edges,  carried 
along  the  natural  line  of  either  the  anterior  or  posterior  border  of  the 
stern omastoid,  is  mu<,'li  less  n()ticeal)le  and  hence  less  objectionable  than 
incisious  carried  either  directly  across  or  in  a  vertical  direction. 

Incisions  commencing  somewhat  posteriorly  and  curving  downward 
and  forward,  and  then  carried  along  the  line  of  the  clavicle,  in  the  great 
majority  of  cases  will  uncover  tumors  low  down  in  tlie  cervical  region ; 
and  the  incision  along  (me  or  the  other  margin  of  the  sternomastoid,  if 
combined  with  an  additional  incision  carried  either  anteriorly  or  pos- 
teriorly, as  the  case  nuiy  be,  will  give  ready  access  to  those  in  the  upper 
lateral  cervical  region.  The  maximum  anumnt  of  room  for  the  operative 
proctMlure,  with  the  mininumi  of  ultinuxte  unsightliness,  will  be  obtained 
by  these  lines  of  incision. 

THE    THORAX. 

Amputation  of  the  Breast. — An  error  nuxy  l)e  charged  against  the 
surgeon  in  cases  in  which  reciu'rence  of  carcinoma  after  amputation  of 
the  breast  takes  place.     While  every  careful  surgeon  will  see  to  it  that 


614  ^   SYSTEM  OF  LEGAL  MEBICIXE. 

no  suspicions  indni'ations  remain,  and  lliat  the  axillaiy  ca'S'ity  is  opened 
up  freely  and  all  glandnlar  tissues  that  can  be  identified  as  such  are 
removed,  vet  it  will  not  be  possible  for  him  to  positively  state,  even  after 
all  of  tliese  precautionary  measures,  that  every  vestige  of  the  disease  is 
extirpated.  In  order  to  still  fui-ther  insure  against  possible  infection 
through  the  mediiun  of  the  pectoral  fascia,  with  its  rich  supply  of  lymph- 
channels  ha'ving  fi*ee  communication  with  the  hTnph-chanuels  of  the 
mammaiy  gland,  an  additional  precaution  consists  in  removal  of  a  por- 
tion or  even  all  of  the  pectoral  muscles  of  the  corresponding  side.  In- 
fected Ipnphatic  glands  are  sometimes  disclosed  which  without  total 
removal  of  both  the  pectoralis  major  and  minor  muscles  would  have 
escaped  detection  and  led  to  so-called  regional  recurrence. 

Lacteal  Fistula. — The  occiuTence  of  a  milk  fistula  following  incis- 
ion for  abscess  of  the  female  breast  may  be  a  source  of  reproach  to  the 
surgeon  who  overlooks  the  anatomical  arrangement  of  the  lactiferous 
tubules,  and  instead  of  making  the  incision  parallel  with  these,  crosses 
them  to  a  greater  or  lesser  extent.  The  resulting  fiLStula  is  a  source  of 
extreme  annoyance  and  is  fi-equently  difficult  to  ciu-e. 

Empyema. — Considerable  anxiety  is  sometimes  caused  by  the  acci- 
dental disappearance  of  a  rubber  di-ainage-tube  within  the  pleural  canity 
during  the  treatment  of  a  case  of  empyema.  Systematic  dilatation  of 
the  original  wound  ti*ack  by  means  of  sponge-tents  or  laminaiia  digitata, 
and  subsequent  vigorous  flushing  of  the  ca^dtv  by  co^nous  injections,  will 
fi-equently  result  in  floating  out  the  tube  without  instituting  a  formal 
operative  procedui'e  and  thus  greatly  alarming  the  patient. 


^-  THE   EXTRE:NnTIES. 

Fractures. — There  are  numerous  complications  and  sequelae  which 
may  occiu*  in  the  coiu'se  of  the  treatment  of  fi'actiu-es,  due  to  cii'cum- 
stances  entii-ely  beyond  the  control  of  the  surgeon,  but  wliich  are  at- 
tributed by  the  patient  and  his  friends  to  the  unskillful  treatment  of  the 
attendant.  The  existence  of  s^-philis  or  some  other  disease  may  prevent 
the  formation  of  proper  callus,  and  an  incomplete  union,  due  to  the  for- 
mation of  a  cicatricial  mass  of  connective-tissue  origin,  take  place,  or  even 
a  pseudarthrosis  result.  "Wliile  the  sui'geon  cannot  be  held  responsible 
for  the  existence  of  the  dyscrasia,  yet  he  cannot  be  held  entirely  blame- 
less i£  the  dyscrasia  is  of  such  a  character  as  to  have  been  amenable  to 
treatment. 

The  interposition  of  the  soft  parts  about  the  site  of  the  fracture  is 
frequently  the  occasion  of  non-union  in  fractures.  Here  the  sm-geon  is 
more  at  fault  than  in  the  former  instance,  particularly  if  he  has  not  in- 
vestigated the  conditions  and  taken  pains  to  provide  against  the  possi- 
l>Llity  of  this  complication. 

Deformity  Following  Fracture. — One  of  the  most  damaging  sequelfe 
(to  the  surgeon's  reputation,  at  least)  of  fractures  is  the  occurrence  of 
deformity  following  the  uni(m  of  a  fractiu-e,  and  the  existence  of  short- 
ening as  compared  ^vith  the  opposite  limb.  A  palpable  bend  or  bow  in 
an  extremity  is  a  constant  reproach  to  the  surgeon's  art,  sometimes  un- 
avoidable, it  is  time,  so  far  as  the  siu-geon  is  concerned,  but,  alas !  too 
frequently  the  result  of  failure  on  his  part  to  bear  in  mind  the  golden 


Si'ltaWAL   MALriiACTWE.  G13 

rule  never  to  permit  the  first  dressing  to  remain  during  the  entire  process 
of  repair,  but  to  remove  this  at  least  on(!e,  and  i)erhaps  oftener,  and  that 
at  a  period  of  time  suflieiently  early  to  permit  of  correction  of  any  exist- 
ing malposition.  Inspection  of  the  injiu-ed  parts  at  the  "  half -healing 
point "  will  save  many  crooked  limbs,  as  well  as  regrets  on  the  j)art  of 
the  surgeon,  since  even  then  the  union  is  so  soft  as  to  permit  of  neces- 
sary correction  of  position. 

Fracture  of  the  Neck  of  the  Humerus. — The  mistake  of  diagnosing 
a  fracture  of  the  neck  of  the  humerus  as  a  dislocation  is  not  infrequently 
made.  The  differential  diagnosis  is  not  always  easily  made,  particularly 
where  consideral)le  swelling  exists.  The  careful  surgeon,  in  case  of 
doubt,  will  prefer  to  d<'lay  his  attempt  at  reduction  until  after  the  swell- 
ing has  subsided,  rather  than  risk  the  infliction  of  further  damage  by 
his  manipulations. 

The  combination  of  a  fracture  of  the  neck  of  the  humerus  and  a  dis- 
location is  sometimes  observed.  Even  when  this  complicated  condition 
is  diagnosticated  the  surgeon  is  at  a  loss  to  decide  upon  the  proper  meth- 
ods of  procedure.  If  he  delays  interference  until  complete  solidification 
at  the  seat  of  the  fracture  is  effected,  the  difficulties  of  reducing  the  dis- 
location are  greatly  increased  over  those  encountered  in  uncomplicated 
dislocations.  The  method  of  McBurney,  of  exposing  the  head  of  the 
bone,  driUing  the  latter,  and  inserting  a  traction-hook  by  means  of  which 
the  displaced  portion  is  replaced  by  directly  applied  force,  probably  offers 
the  patient  the  very  best  chance  of  a  useful  arm. 

Injury  to  the  Circumflex  Nerve  Simulating  Dislocation  of  the 
Shoulder. — The  course  which  this  nerve  takes  around  the  neck  of  the 
humerus,  as  well  as  its  relations  to  the  shoulder-joint,  render  it  especially 
liable  to  injury  from  blows  or  falls  upon  the  shoulder.  Dislocations  of 
the  humerus  are  also  occasionally  followed  by  paralysis  in  the  course  of 
the  distribution  of  the  nerve.  In  chronic  inflammatory  conditions  in  the 
shoulder- joint  the  nerve  may  become  involved  in  a  neuritic  process.  As  a 
result  of  interference  with  the  supply  of  the  circumflex  nerve  there  is  a 
noticeable  wasting  of  the  structures  which  clothe  the  joint ;  and  suits  for 
malpractice,  based  upon  these  appearances  and  a  failure  on  the  part  of 
tlie  surgeon  to  discover  and  reduce  a  supposed  dislocation  of  the  shoulder, 
have  resulted.  With  extreme  atrophy  of  the  deltoid  muscle  there  is  a 
marked  prominence  at  the  acromion  process  and  a  decided  groove  per- 
ceptible through  the  atrophied  muscle  between  the  head  of  the  humerus 
and  tlie  articular  surface  of  the  scapula.  Under  these  circumstances  the 
resemblance  to  a  dislocation  is  striking,  until  manipulation  discloses  the 
real  condition. 

Fractures  near  the  EIbow=joint. — Fractures  in  the  neighborhood 
■of  or  involving  the  elbow- joint  are  apt  to  give  rise  to  contractures  and 
anchylosis  in  this  articulation,  from  inflammatory  conditions  the  resiilt 
of  the  injury.  While  these  are  frequently  unavoidable,  and  no  one  may 
know  beforehand  in  the  individual  case  to  what  extent  these  may  imjiair 
the  usefulness  of  the  arm,  the  extent  of  the  loss  of  function,  when  it  does 
occur,  will  depend,  in  great  measure,  on  the  care  which  the  surgeon  exer- 
cises in  placing  the  member  under  conditions  in  which,  should  anchylosis 
follow,  the  patient  may  be  able  to  perform  certain  needful  movements. 
An  arm  anchylosed  in  the  straight  position,  or  nearly  s(\  will  be  practi- 
cally useless,  and  one  sharph'  flexed  will  be  nearly  so.     With  the  forearm 


616  ^   SYSTEM  OF  LEGAL  MEDIC IXE. 

at  right  angles  to  tlie  arm,  a  compensatory  increase  of  the  range  of  mo- 
tion at  the  shoulder  occurs,  and  the  patient  will  be  able  to  execute  move- 
ments ^dth  the  extremity  to  a  siu'prising  extent. 

While  the  treatment  of  a  fractui-e  of  the  arm  in  this  locahty  in  the 
straight  or  extended  position  (anchylosis  not  occiUTing)  gives  a  more 
sjanmetrically  perfect  arm,  for  the  reason  that  the  normal  angle  which 
the  radius  and  ulna  bear  to  the  hiunerus  is  preserved  and  with  it  the  so- 
called  carr}dng  function,  yet,  as  before  stated,  no  one  may  know  before- 
hand whether  or  not  the  inflammatory  changes  will  be  such  as  to  j)revent 
fi'ee  motion  at  the  elbow- joint.  Hence,  in  order  to  prevent  this  undesir- 
able complication,  the  surgeon  will  do  well  to  carefully  study  each  case,, 
and  endeavor,  in  the  event  of  the  probabilit}^  of  anchylosis,  as  e^dnced 
by  the  presence  of  severe  injury  to  the  joint  and  extensive  extravasation 
in  the  soft  parts,  to  obtain  early  passive  movements.  The  arm  is  to  be 
retained  at  a  right  angle  to  the  forearm  in  the  intervals,  if  these  move- 
ments produce  increase  in  the  inflammatory  conditions  to  the  extent  to- 
indicate  their  discontinuance.  In  other  words,  although  rest  is  indicated 
when  the  inflammatory  process  is  intra-articular  in  its  location,  motion  is 
indicated  if  the  inflammation  is  extra-articular.  If  the  inflammation  be 
both  intra-  and  extra-articular,  in  order  to  meet  the  fii'st-named,  rest  is 
indicated ;  but  this  prolonged  to  the  period  sometimes  necessary  to  bring 
about  complete  restoration  of  the  joint  will  lead  to  contracture  of  the 
muscular  and  tendinous  structures  and  restriction  of  motion;  at  the 
same  time  adhesions  will  form  within  the  joint  itself. 

It  would  seem  that  compromise  measures,  consisting  of  fixation  of 
the  joint  at  a  right  angle  in  the  intervals  by  means  of  a  sphnt,  and  the 
application  of  massage,  serve  best  in  these  cases.  It  is  also  to  be  noted 
that  after  the  intra-articular  inflammation  has  subsided  and  some  range 
of  movement  is  accomplished,  this  is  generally  increased  by  the  patient's- 
own  voluntary  movements.  This  is  particularly  true  in  the  case  of  young- 
children. 

The  surgeon  may  remove  the  bandages  and  splints  at  the  end  of  a 
week  or  ten  days  from  the  date  of  the  injury,  and  practice  massage  him- 
self. The  application  of  this  valuable  therapeutic  measm-e  should  not 
be  intrusted  to  a  lay  person,  or  even  a  professional  massem-,  at  this  time, 
for  the  reason  that  an  intelligent  reapphcation  of  the  splint  and  band- 
ages follomng  the  massage  is  necessary.  Later  on,  when  consolidation 
has  progressed  sufiiciently  far  and  improvement  in  the  intra-articular  in- 
flammation will  warrant  it,  passive  movements  are  to  be  added.  Should 
the  latter  increase  the  inflammatory  action,  they  must  be  abandoned  for 
the  time  being.  All  this  requires  the  personal  supervision  of  the  sur- 
geon, and  failure  to  give  this  to  the  case  may  bring  him  reproach.  He 
caimot  be  held  responsible  for  anchylosis  resulting  fi-om  ^'icious  callus. 

Fractures  at  the  Lower  End  of  the  Radius. — Impairment  of  func- 
tion following  fractm^es  at  the  lower  end  of  the  radius  results  (1)  from 
failure  to  properly  disentangle  the  small  portion  of  l3one  torn  off  by  for- 
cible extension  of  the  hand,  and  which  occurs  because  of  the  toiigh  and 
unyielding  character  of  the  anterior  radiocarpal  ligament,  or  (2)  the 
swelling  and  congestion  consequent  upon  the  injury  inflicted  upon  the 
surrounding  soft  parts  ma}'  pass  from  the  stage  of  active  hj-peraemia  to 
inflammation,  and  this,  invohdng  the  adjoining  muscular  aponeuroses 
and  tendinous  sheaths,  produce  fixation  of  these.     This  is  particularly 


SURGICAL   MALPRACTICE.  G17 

true  if  a  splint  apparatus  that  extends  from  the  upper  portion  of  the 
forearm  to  the  finger-tips  is  emphjyed  and  permitted  to  remain  undis- 
turbed during  the  entire  period  of  repair. 

In  the  nuijority  of  eases  very  sKght  if  any  retentive  apparatus  \\i\\  l)e 
necessary  from  the  first.  The  surgeon  who  omits  to  apply  any  apparatus 
whatever  will  be  less  frequently  reproached  than  he  who  applies  a  fixation 
splint  and  removes  it  after  the  end  of  three  or  four  weeks  for  tlie  first 
time.  In  the  first  instance  the  normal  m()%'ements  of  the  wrist  and  finger 
joints  are  more  (piickly  restored,  and  inflammatory  adhesions  are  not  so 
apt  to  bind  down  muscular  and  tendinous  sti-uctures.  In  the  second  the 
parts  are  held  rigidly  in  a  position  to  favor  coutra('ture  of  the  niuscles 
and  tendons  as  well  as  the  occurrence  of  fibrous  adhesions  within  and 
upon  the  sheaths  of  the  latter. 

Where  the  use  of  a  sinix)le  roller-bandage  does  not  suffice  for  sup- 
port, a  splint  wliich  si  i all  hold  the  hand  in  the  position  of  slight  palmar 
flexion  may  be  used.  But  whether  the  hand  and  forearm  be  enveh)ped 
in  a  simple  roller  bandage  or  supported  upou  a  splint,  the  important 
point  in  the  treatment  is  to  avoid  the  impairment  of  function  due  to  fix- 
ation of  the  tendons  and  to  adhesions  within  the  joints.  The  means  best 
calculated  to  accomplish  this  is  by  the  early  and  persistent  use  of  daily 
massage  and  passive  movements.  As  in  the  case  of  the  elbow- joint,  the 
surgeon  should  perform  these  for  the  first  three  weeks  himself,  at  the  end 
of  Avliich  time  he  may  intrust  them  to  a  professional  masseur. 

Gangrene  of  the  Hand  Following  Fracture  of  the  Radius. — Espe- 
cial care  should  be  exercised  in  the  appheatiou  of  a  plaster-of-Paris  l:)and- 
age  to  the  forearm  in  fractures  of  this  part  which  result  from  direct  or 
indirect  force.  Surgeons,  as  a  rule,  avoid,  as  far  as  possible,. such  appli- 
cation, on  account  of  the  liability  of  the  occm-rence  of  rapid  swelling  and 
the  danger  of  gangrene.  The  occurrence  of  blood  stasis,  as  evinced  l>y 
the  failure  of  the  blood  to  refill  the  vessels  beneath  the  finger-nails 
promptly  after  it  has  been  forced  out  by  pressure,  is  an  early  and  infal- 
lible test.  The  uad  remains  white ;  even  if  the  color  eventually  returns, 
if  it  is  delayed  beyond  a  few  seconds  the  surgeon  will  do  well  to  take 
note  of  any  complaints  of  pain  on  the  part  of  the  patient,  and  be  pre- 
pared at  short  notice  to  remove  the  baudages. 

Slalposition  of  the  fragments  in  fi-acture  of  the  radius  may  produce 
gangrene  of  the  hand  where  no  bandage  whatever  has  been  applied, 
through  pressiu'e  upon  the  blood-vessels.  Changes  in  the  walls  of  the 
bh)od-vessels  may  lead  to  thrombostasis,  this  extending  to  the  capillary 
area. 

Gangrene  Following  Fracture  of  a  Lower  Extremity. — This  is 
an  extremely  unfortunate  com})lication.  With  the  rare  exception  of  the 
<5ases  in  wliich  the  gangrene  results  from  simultaneous  contusion  of  the 
blood-vessels  or  pressure  from  displaced  fragments,  gangrene  of  a  lower 
extremity,  the  site  of  a  simple  fractm-e,  is  due,  in  this  class  of  eases,  to 
the  too  early  application  of  a  fixed  dressing,  such  as  plaster-of-Paris,  sili- 
cate of  soda,  or  starch.  It  may  also  arise  from  the  application  of  an  or- 
dinary splint.  The  occuri-ence  of  pain,  with  appeals  on  the  part  of  the 
patient  to  remove  the  bandages,  if  unheeded,  may  lead  to  the  most  dis- 
astrous consequences.  Under  such  circumstances  the  surgeon  will  be 
Iield  responsible  for  the  loss  of  the  limb,  which  is  the  imn-ital)le  result. 

The  fact  should  never  be  lost  sight  of  that  the  failure  to  apply  any 


618  A  SYSTEM  OF  LEGAL  MEDICINE. 

sort  of  apparatus  for  the  first  ten  days,  save  a  pillow  support,  can  never 
result  in  harm  to  the  injured  member.  At  the  end  of  this  time  the 
swelling,  wiiich  is  the  cause  of  the  mischief,  will  have  reached  its  maxi- 
mum. Correction  of  malposition,  and  the  application  of  fixed  di'essing 
or  retentive  apparatus,  may  now  be  employed.  In  about  ten  days  from 
this  time  whatever  sweUing  still  remains  will  have  subsided,  and  the  (h-ess- 
ings  may  be  removed  and  applied.  Tliis  will  also  aiford  an  opportunity 
to  inspect  the  parts  and  correct  any  undesirable  conditions  winch  may 
be  present.  These  remarks  are  particularly  applicable  to  fractm-es  wliich 
are  the  result  of  direct  force.* 

Injuries  to  the  Hip=joint. — This  articulation  is  deeply  placed,  sur- 
rounded by  large  masses  of  muscular  tissue,  and  is  capable  normally  of 
a  great  variety  of  movements.  In  the  young  both  the  aponeurotic  and 
ligamentous  structures  in  and  about  the  joint  yield  considerably,  while 
the  bony  structures  are  in  a  condition  to  withstand  considerable  force 
before  giving  way.  Later  in  life  the  fibrous  structures  become  tough 
and  unyielding,  while  the  bone,  owing  to  rarefying  processes,  is  more  or 
less  brittle  and.  easily  broken.  Hence  it  follows  that  in  early  and  middle 
life  dislocations  oceui'  most  frequently,  while  in  the  later  years  of  life 
fractures  occur*  more  commonly. 

The  points  in  the  differential  diagnosis  of  these  two  great  classes  of 
injury  are  easily  made  out  in  t3q3ical  cases.  Hence  the  error  of  mistak- 
ing a  dislocation  for  a  fracture,  and  rice  versa,  is  not  frequently  made. 
In  a  given  case  of  iujnry  to  the  hip-joint,  however,  in  which  the  existence 
of  a  dislocation  can  be  taken  out  of  the  consideration,  there  may  still  be 
an  absence  of  the  usual  signs  of  fracture,  and  the  surgeon  be  led  into 
error.  This  arises  fi'om  the  fact  that  a  large  proportion  of  cases  occiu- 
from  falls  upon  the  trochanter,  the  effect  of  which  is  to  force  the  distal 
into  the  proximal  fragment,  with  consequent  impaction.  Under  these 
circumstances  the  characteristic  shortening  and  preternatural  mobility 
■vvdll  be  absent.  Crepitus  "^tH  likewise  be  absent,  although  this  symptcnn 
is  of  less  value  in  the  diagnosis  of  fractures  in  general,  and  particularly 
those  in  the  neighborhood  of  the  hij)-joint,  than  is  generally  supposed. 
It  cannot  be  obtained  when  impaction  is  present,  and  any  attempt  to 
elicit  it  by  manipulation  may  result  in  breaking  loose  the  impaction  and 
producing  a  worse  condition  than  previously  existed. 

The  occurrence  of  impaction  will  depend  to  some  extent  upon  the 
location  of  the  hue  of  fracture.  This  will  most  frecjuently  be  present 
when  the  bone  gives  way  at  the  base  of  the  neck,  and  this  variety  is  the 
most  common.  It  corresponds  to  the  extracapsular  fractures  of  the  older 
wi'iters.  Impaction  is  rarely  present  in  those  fractures  which  cross  the 
narrow  part  of  the  neck  either  transversely  or  obliquely,  and  which,  in 
the  main,  are  within  the  capsule. 

An  injury  to  the  hip- joint  in  which  there  is  loss  of  function,  as  shown 
by  inability  on  the  part  of  the  patient  to  raise  the  limb  from  the  level  of 
the  body  while  lying  upon  the  back,  slight  shortening,  and  e version  of 
the  foot  which  cannot  be  converted  into  a  complete  inversion,  in  the 
gi'eat  majorit}^  of  cases  is  an  impacted  fi'acture  of  the  base  of  the  neck 
of  the  femur.  If  the  patient  is  past  middle  life  and  a  woman  the  chances 
are  still  greater  of  this  condition  being  present. 

*  Nussbaum,  Aerztl.  Central  Anzeifjcr,  1887,  No.  18. 


SURGICAL   MALrRACTICE.  (J]  (J 

The  oversion  of  tlie  limb  present  in  impaeted  fraeture  of  tlie  base  of 
the  neek  is  usually  comparatively  slight,  while  that  present  in  non-im- 
pacted fraeture  is  greater.  This  is  also  true  of  the  shortening.  The  en- 
tanglement of  the  fractured  surfaces  \\'iU  limit  the  shortening,  while  the 
fact  that  the  posterior  surface  of  the  neck  is  im2)acted  to  a  greater  extent 
than  in  front  accounts  for  the  partial  l)ut  quite  constant  eversion,  as  well 
as  the  difficulty  in  overcoming  the  latter.  Therefore  slight  shortening 
(less  than  an  inch),  combined  with  slight  or  only  partial  eversion,  should 
awaken  sus})icion  of  this  injury,  and  nianii)ulation  should  Ije  very  care- 
fully made.  On  the  other  hand,  the  presence  of  considerable  shorten- 
ing, together  with  decided  or  complete  eversion,  Avill  suggest  a  fracture  of 
the  smaller  portion  of  the  neck  of  the  femur.  These  two  points,  namely^ 
the  amount  of  shortening  and  the  extent  of  the  eversion,  should  be  ascer- 
tained before  manipulation  of  the  limb  for  diagnostic  jDrnposes  is  made. 

Failure  of  union  in  fracture  of  the  neck  of  the  femur  will  occiu-  in  a 
certain  proportion  of  cases.  This  is  more  lilvely  to  Ije  jjresent  in  cases  in 
Avhicli  the  fracture  is  at  the  narrow  portion  of  the  neck  (intracapsular)^ 
for  the  reason  that  the  nutrition  of  the  proximal  fragment  is  generally 
so  interfered  mth  as  to  prevent  repair.  In  some  instances  the  peri- 
osteum is  not  torn  completely  across  and  nnion  follows.  In  fi-actures  at 
the  base  of  the  neck  (extracapsular)  non-nnion  may  follow  from  those 
causes  which  produce  the  same  conditions  elsewhere,  namely,  f ailiu"e  to 
seciu-e  or  maintain  proper  apposition  of  the  l)roken  surfaces,  rarefying 
processes  either  pi-eceding  or  following  the  injury,  or  arrest  of  the  evolu- 
tion of  the  callns  l3efore  it  has  entered  iipon  the  stage  of  ossification. 

Fi-acture  of  the  neck  of  the  femur  has  occm-red  dm-ing  attempts  at 
reduction  of  a  dislocation.  Tliis  is  an  nnfortnnate  accident,  inasmuch 
as  it  renders  reduction  practically  impossible,  and  if  intracapsidar,  is 
likely  to  be  followed  by  necrosis  of  the  head,  for  the  reason  that,  the  liga- 
mentnm  teres  being  separated  by  the  dislocation,  the  nutrition  of  bone  at 
this  point  is  destroyed. 

Hip  Disease  in  Children. — The  importance  of  an  early  diagnosis  of 
morbus  coxarius  can  scarcely  be  overestimated.  There  are  several  con- 
ditions which  may  simulate  this  disease  more  or  less  closely,  and  which 
it  behooves  the  surgeon  to  keep  before  him  in  examining  cases  in  which 
the  symptoms  point  to  disease  of  the  coxofemoral  articulation. 

In  the  first  place,  it  is  not  an  infrequent  experience  in  the  metropolis 
to  have  children  suffering  from  hip  disease  brought  to  the  sm-geon's  of- 
fice with  a  knee-joint  painted  with  tincture  of  iodine  or  marked  by  the 
I)eculiar  discoloration  following  a  blister,  in  which  the  diseased  condition 
realh'  exists  in  the  hip-joint.  The  patient's  complaints  refer  the  pain 
to  the  region  of  the  inside  of  the  thigh  just  above  the  knee-joint,  or  even 
at  the  knee-joint  itself.  The  explanation  of  this  is  furnished  bj'  the  inti- 
mate relations  and  anastomoses  of  the  sciatic,  obturator,  and  anterior 
crural  nerves. 

An  injury  of  the  hip-joint  in  a  child  may  give  rise  to  synovitis  's\-itliout 
necessarily  being  followed  by  true  hip  disease.  While  it  is  desira))le  to 
make  a  proper  diagnosis  whenever  possible,  the  error  indicated  is  of  but 
minor  importance  compared  to  some  others  that  will  be  mentioned,  pro- 
vided the  synovitis  is  treated  properly,  for  the  reason  that  this  will  in- 
volve rest,  counter-irritation,  and  the  other  measures  applicable  to  hip 
disease  in  its  earliest  stae:e. 


620  ^   SYSTEM  OF  LEGAL  MEDICINE. 

Congenital  dislocation  of  the  liip  is  a  more  commou  condition  than  is 
usually  considered,  and  may  be  mistaken  by  a  careless  observer  for  liip- 
joint  disease.  During  the  year  ending  September,  1891,  twenty-five  cases 
were  presented  at  the  New  York  Hospital  for  Ruptured  and  Crippled,  or 
more  than  one  for  every  ten  cases  of  tubercular  disease  of  the  hip.  A  care- 
ful inquiiy  will  usually  elicit  the  fact  that  the  child  limped  from  the  time 
that  it  began  to  walk,  and  examination  will  disclose  the  following  ob- 
jective symptoms :  (1)  a  peculiar  waddling  gait  in  connection  with  the 
limp ;  (2)  a  shortening  of  a  half -inch  oi'  more ;  (3)  elevation  of  the  tro- 
chanter (in  fat  children  this  is  not  always  easily  defined) ;  (4)  the  limited 
motion  is  mechanical,  and  arises  from  the  relations  of  the  head  of  the 
femur  to  the  rim  of  the  aeetabulnni,  and  is  not  due  to  muscular  spasm 
.as  in  hip  disease.     In  addition  there  will  be  absence  of  tenderness. 

Children  with  hip  disease  are  not  infrequently  treated  for  rheumatism. 
The  careful  practitioner  will  not  fail  to  suspect  the  true  nature  of  the 
affection  at  hand  if  he  will  but  bear  in  mind  that  monarticular  rheuma- 
tism in  children  is  a  very  rare  disease,  and  that  the  invasion  of  the  latter 
is  less  insidious,  the  tenderness  and  pain  are  greater,  and  motion  much 
more  limited  from  the  commencement,  than  in  true  hip  disease.  Surgical 
should  replace  purely  medical  treatment  in  a  very  few  days,  if  decided 
improvement  does  not  prompt^  follow  the  latter. 

Inflamed  inguinal  glands,  due  either  to  tubercular  infection  or  the  ac- 
cumulation of  subpreputial  secretions,  may  cause  a  limp  and  limitation 
of  the  movements  of  the  joint.  The  error  of  mistaking  this  for  hip  dis- 
ease is  not  a  very  serious  one  from  the  medico-legal  standpoint,  and 
should  not  continue  longer  than  necessary  to  make  a  local  exami- 
nation. 

Limitation  of  the  movements  of  extension  and  consequent  limp  may 
be  early  symptoms  in  osteitis  or  Fotfs  disease  in  the  lumbar  region,  and 
lead  the  surgeon  into  error.  Every  endeavor  should  be  made  to  recog- 
nize and  treat  Pott's  disease  of  the  spine  early  in  the  affection,  for  the 
reason  that  if  this  be  deferred  until  a  protuberance  appears,  the  disease 
will  be  well  advanced,  with  no  possible  hope  of  overcoming  the  existing 
deformity,  to  say  nothing  of  the  dangers  arising  from  the  destructive 
bone-lesion.  Save  in  those  instances  in  which  rest  in  the  recumbent 
position  is  employed,  as  advocated  by  some  surgeons  in  the  treatment 
of  early  hip  disease,  the  mistake  of  treating  a  case  of  low  Pott's  disease 
for  hip  disease  would  be  a  serious  one,  and  hkely  to  delay  the  proper 
treatment  until  either  deformity  or  tubercular  ahscess,  or  both,  compli- 
cate the  case.  If  flexion,  which  is  normal,  be  first  employed  in  order  to 
completely  relax  the  psoas  muscle,  all  other  movements  of  the  hip-joint 
will  be  found  to  be  easily  performed.  Iriitation  of  the  psoas  by  any 
diseased  condition  of  the  lumbar  vertebra  will  cause  rigidity  of  this  region 
instead  of  increased  flexibility,  as  found  upon  attempts  to  produce  com- 
plete extension  of  the  thigh  in  hip  disease.* 

Resection  of  the  Knee. — After  exposure  of  the  joint  surfaces  the 
popliteal  artery  may  be  wounded  either  while  the  siu'geon  is  in  the  act 
of  dividing  the  crucial  ligaments  or  while  remo\dng  the  articular  surfaces. 
The  occurrence  of  this  accident  is  most  unfortunate,  for  the  reason  that, 
following  as  it  does  the  division  of  the  freely  anastomosing  articidar  ar- 

*  Dr.  Walter  C.  Wood,  Brool-hjn  Medical  Jnuniah  July,  1894. 


SURGICAL  MALPBACTICE.  G21 

teries,  the  only  cliannc4  of  .sni)])ly  to  the  leg  is  destroyed,  and  amputation 
is  the  only  resource  left  in  ortk-r  to  save  the  patient. 

In  resection  of  the  knee-joint  the  operator  should  bear  in  mind  the 
ueeessitj^  of  sparing  the  epiphysis  wlienever  possible.  In  case  of  injury 
to  this  important  structure,  particularly  in  growing  ehildi'en,  the  limb 
becomes  relatively  shorter  on  account  of  the  diminished  rate  of  gi-owth 
as  compared  with  that  of  the  opposite  limb. 

Tenotomies  and  Myotomies. — These  have  been  the  occasion  of  gi^ave 
accidents.  The  (h'<'p  peroneal  nerve  has  been  injured  in  tenotomy  of  the 
biceps  femoris,  and  hemorrhage  from  the  postei'ior  tibial  artery  is  a  not 
infrequent  accident  oc<!urriug  in  connection  with  the  connnon  operation 
of  the  division  of  the  tendo  Acldllis.  In  the  division  of  the  groups  of 
muscles  that  move  the  head,  for  wryneck,  it  is  often  extremel}'  difficult 
to  determine  just  which  muscles  are  at  fault,  and  the  operator  may  find 
himself  in  the  position  of  having  divided  a  number  of  these  unnecessarily 
before  he  finally  succeeds  in  rectifying  the  position  of  the  head,  if,  in- 
deed, he  does  not  fail  in  accomplishing  his  object  altogether,  even  after 
extensive  mutilation. 

Contracture  and  Anchylosis. — Accidents  are  likely  to  happen  in  the 
attempt  to  apply  hviseinod  force  for  overcoming  anchylosis.  Failure 
to  divide  muscular  contractions  pi-eliminarily  may  result  in  the  ruptui-- 
ing  of  these  in  localities  in  which  harm  may  arise  or  even  considerable 
damage  be  inflicted. 

An  unfortunate  circumstance  occurring  while  attempting  to  break 
up  a  bony  anchylosis  consists  in  an  accidental  fracture  of  the  bone  at 
some  point  in  the  diaphysis,  instead  of  giving  wa}^  at  its  adventitious 
attachuients  in  the  joint.  A  worse  condition  than  that  for  which  the 
operation  was  undertaken  follows.  Hence  the  importance  of  the  precau- 
tion so  rigidly  insisted  upon  by  some  authorities  to  first  forcibly  flex  the 
joint,  thus  breaking  up  adliesions  bj^  movements  in  a  direction  the  least 
calculated  to  do  harm,  before  attempting  the  more  dangerous  movements 
of  extension. 

An  important  artery  may  be  embedded  in  the  rigid  mass  of  exuda- 
tion about  the  joint,  and  this  being  ruptured,  an  enormous  subcutaneous 
hemorrhage  may  occur,  necessitating  immediate  amputation.  The  press- 
ure of  the  surrounding  mass  may  mask  this  symptom,  and  the  surgeon 
be  not  aware  of  its  presence  until  loss  of  sensation  and  natural  warmth, 
and  finally  gangrene  of  the  periphery  of  the  limb,  lead  to  an  imTstigRtion, 

Amputations. — In  amputations  the  flaps  may  not  be  made  sufliciently 
long,  and  an  exceedingly  sensitive  condition  of  the  stump  arises  from  a 
tightly  drawn  line  of  cicatrix,  which  nmybe  the  occasion  of  great  suffer- 
ing to  the  patient  for  the  remainder  of  his  life.  The  neglect  to  draw 
down  and  divide  the  larger  nerve  trunks  upon  a  higher  level  than  the 
flaps  frequently  results  in  their  imi)risonment  in  the  cicatricial  tissue. 
The  most  excruciating  pains,  referable  to  the  area  of  former  distril)ution 
or  the  site  of  the  nerve  stinnps  themselves,  may  follow. 

It  would  seem  to  be  almost  impossible  that  an  accident  such  as  the 
amputation  of  the  ^vi'ong  foot  could  occui',  but  this  is  said  to  have  hap- 
pened at  a  clinic  in  Europe  during  the  last  century.  A  man  was  suffer- 
ing fnun  extensive  ulceration  of  both  feet,  one  of  which  Avas  condemned 
for  amputation,  while  the  other  was  decMued  to  be  ameuMble  to  treatment. 
Both  feet  were  bandaged.     The  bandages  were  removed  from  one  foot, 


622  -^   SYSTEM  OF  LEGAL  MEDICINE. 

and  tliis  Avas  auiputated.  Upon  removing  the  dressings  from  tlie  otlier 
foot  it  was  discovered  that  the  one  which  had  been  thought  to  be  curable- 
had  been  removed,  while  that  which  had  been  regarded  as  incurable  re- 
mained. The  sm-geon  made  ever}^  effort  to  cure  the  foot,  and  finally- 
succeeded. 

The  late  Dr.  Daniel  Ayres,  of  Brooklyn,  related  to  the  writer  that  he 
once  witnessed  an  amputation  of  the  hip-joint  upon  the  battle-field  during 
the  late  war,  in  which  the  operator,  in  the  excitement  of  the  moment, 
cut  the  flaps  from  the  parts  above  the  line  of  section  of  the  muscular 
structiu'es,  and  consequently  removed  them  with  the  amputated  limb. 


THE  ABDOMINAL  AND   PELVIC   CAVITIES. 

The  Diagnosis  of  Tumors  of  the  Abdomen  and  Pelvis. — Some  of 
the  most  serious  mishaps  in  surgical  practice  have  occurred  in  connection 
with  the  differential  diagnosis  of  abdominal  and  pelvic-  tumors.  To- 
enumerate  all  of  the  errors  into  which  the  surgeon  may  fall  without  due 
care  would  be  impossible  in  this  connection. 

Hysterical  contractions  of  isolated  portions  of  the  muscular  M^all  of 
the  abdomen  may  simulate  a  tumor,  and  repeated  examinations  may  be 
necessary  in  order  to  escape  this  error.  Once,  however,  the  fact  of  the 
existence  of  a  tumor  has  been  established,  many  difficulties  arise  to  baffle 
the  surgeon  in  his  attempts  to  differentiate  between  the  various  neoplasms 
which  occur  in  these  regions.  For  instance,  an  ascites  having  its  origin 
in  tubercular  peritonitis,  with  adhesions  of  the  intestines  to  the  neigh- 
borhood of  the  vertel^ral  column  and  the  uterus  fixed  high  up  at  the- 
pehdc  brim,  very  closely  resembles,  in  its  objective  symptoms,  an  ovarian 
cyst.  Instead  of  the  intestines  floating  upon  the  surface  of  the  fluid  and 
the  uterus  forced  downward,  the  reverse  obtains ;  a  flat  percussion-note- 
exists  anteriorly,  and  the  tympanitic  note,  due  to  the  presence  of  the  in- 
testines, is  heard  posteriorly,  as  in  ovarian  cystoma. 

Simpson  mentions  six  cases  in  which  the  abdomen  was  opened  and 
only  a  tympanitic  condition  of  the  bowels  found.  The  writings  of  Mai- 
sonneuve,  Lizars,  King,  Smith,  McDowel,  and  Dolhof  contain  many  simi- 
lar operative  errors.* 

An  hour-glass  contraction  of  a  distended  urinary  bladder  has  been 
mistaken  for  a  ay  at  of  ihe  ovary ;  the  diagnosis  was  only  established  b}'" 
keeping  up  steady  pressure  upon  the  lower  portion  of  the  abdomen  dur- 
ing catheterization.  In  another  instance  an  ovarian  cyst  existed  in  con- 
junction with  an  hour-glass  contraction  of  the  bladder.  (Nussbaum.) 
The  operator  in  this  case  did  not  discover  the  true  state  of  affairs  until 
the  bladder  had  been  wounded. 

Differentiation  between  a  neoplasm  and  pregnancy,  either  normal  or 
extra-uterine,  is  sometimes  extremely  difficult.  No  less  an  authority  than 
Sir  Spencer  Wells  once  opened  the  abdomen  for  a  supposed  ovarian  cys- 
toma, and  even  proceeded  so  far  as  to  puncture  the  uterus.  He  was 
compelled  to  empty  the  latter  at  once  by  reason  of  the  protrusion  of  the 
fetus  through  the  opening  made  by  the  large  trocar.  Attempts  to  force 
the  contents  of  the  uterus  back  through  the  opening  only  resulted  in 

*  Spiegelberg,  Die  Diar/nose  der  Elemtoclcs-Tnmorcn,  etc. 


SURGICAL  MALPJiACTICE.  G23 

rupture  of  its  walls.  Two  similar  cases,  ending-  fatally,  are  recorded  by 
Hegar  and  Kaltenbach. 

A  case  is  recorded  in  wliicli  a  tuljal  pregiuincy  was  mistaken  for  a. 
retroversion  of  the  uterus.  Reduction  was  attempted,  and  was  followed 
by  death  from  peritonitis. 

Hugier  once  diagnosticated  an  extra-uterine  pregnancy,  and  brought 
the  case  before  the  Academy  of  Medicine  in  Paris.  A  commission  ap- 
pointed to  investigate  the  case  agreed  with  Hugier.  Dubois,  however, 
suggested  tlie  possibility  of  liorinal  pregnancy.  With  the  oc(;urrence  of 
labor  abdominal  section  was  determined  upon.  While  the  preparations 
for  the  operation  were  being  made,  Roux  nuide  an  examination  and  found 
the  liead  engaged.     The  child  was  born  per  cias  natnrcdps'. 

I  have  twice  seen  the  pregnant  uterus  removed  together  with  large 
uterine  fibromata.  Upon  incising  the  tumor  and  uterus  a  three  months' 
fetus  was  disclosed. 

Some  exceedingly  sad  instances  have  occurred  in  which,  an  abdominal 
tumor  being  present,  unmarried  patients  have  been  accused  of  jiregnancy. 

Paracentesis  Abdominis. — This  operation  is  frequently  performed 
by  those  who  have  very  little  experience  in  operations  in  general,  and 
who  fail  utterly  to  appreciate  the  fact  that  thei'e  are  certain  precautious 
to  be  observed  in  spite  of  the  apparent  simplicity  of  the  operation.  The 
withdrawal  of  the  entire  quantity  of  ascitic  fluid  causes  the  vessels  with- 
in the  abdominal  cavity  to  become  overtilled  in  the  attempt  on  the  part 
of  the  circulating  fluid  to  till  the  vacuum.  This  may  lead  to  rupture  of 
some  of  these  vessels,  or  to  dangerous  cerebral  ana?mia. 

Wliere  the  abdominal  walls  are  thick  and  edematous  (combination  of 
ascites  and  anasarca),  the  cannula  may  fail  to  reach  the  ascitic  fluid ;  yet 
the  escape  of  a  small  quantity  of  fluid  from  the  connective  tissue  of  the 
abdominal  wall  at  first  misleads  the  practitioner,  and  he  is  very  nnich 
perplexed  at  the  situation.  He  fails  to  realize  that  the  cannula  has  not 
entered  the  peritoneum,  and  is  led  to  believe  either  that  a  wrong  diag- 
nosis has  been  made  or  that  a  loop  of  intestine  has  fallen  across  the  open- 
ing of  the  cannula.  This  will  lead  to  either  fruitless  efforts  to  clear  the 
cannula  or  an  abandonment  of  the  operation  altogether.  Replacing  the 
trocar  and  making  deeper  penetration  Avill  clear  up  the  mystery. 

Intestinal  Obstruction  and  Hernia. — Abdominal  section  not  infre- 
quently fails  to  disclose  the  cause  of  acute  obstruction ;  not  only  this, 
but  the  manipulation  of  the  intestines  in  the  search  sometimes  removes 
the  obstacle.  Again,  it  sometimes  happens  that  the  obstacle  is  found 
but  cannot  be  relieved,  or,  being  relieved,  as,  for  instance,  a  torsion  in 
the  long  axis  of  the  bowel,  it  recurs  as  soon  as  the  restraining  hand  is  re- 
moved. Under  these  circumstances  an  enterotomy  is  preferable,  if  the 
operation  has  been  greatly  prolonged  in  the  search  for  and  attempts  at 
removal  of  the  ol:)stacle,  to  immediate  resection  or  lateral  anastomosis. 
The  latter  procedure  may  be  instituted  later  on. 

The  mistaking  of  an  inflanuHl  strangulated  hernia  for  an  inguinal 
abscess  may  do  incalculalile  harm  and  lead  to  most  disastrous  conse- 
quences;  mistaking  suppurating  inguinal  glands  for  hernia  will  scarcely 
result  in  damage  to  the  patient.  The  attempt  to  reduce  the  inflamed 
mass  by  taxis  in  the  latter  case  nuist  soon  be  abandoned,  and  the  careful 
dissection,  layer  by  layer,  of  the  tumor  until  an  abscess  cavity  is  readied 
is  far  preferable  to  thrusting  a  knife  into  the  mass  and  being  greeted 


^24  -^   SYSTEM  OF  LEGAL  MEDICINE. 

■with  gas  of  intestinal  origin,  further  investigation  revealing  the  presence 
of  a  loop  of  intestine.  Following  falls  from  a  height,  swellings  in  the 
groins  have  been  mistaken  for  hematocele,  when  hernia  has  been  present 
and  the  result  of  the  accident.  To  carefully  dissect  down  upon  a  hemat- 
ocele imder  the  impression  that  it  is  a  hernia  is  an  innocent  mistake ; 
to  incise  at  a  single  stroke  a  hernia  in  the  belief  that  it  is  a  hematocele 
is  a  most  grievous  error. 

Before  the  days  of  aseptic  and  antiseptic  surgery  it  was  the  rule  in 
performing  herniotomy  to  endeavor  to  relieve  the  obstacle  to  reduction 
without  opening  the  sac,  on  account  of  the  dangers  which  the  peritoneal 
section  then  involved.  Sometimes  the  reduction  en  masse  resulted  in  a 
failure  to  relieve  the  strangidation  w-hich  still  existed  within  the  sac. 
Reduction  by  taxis  likewise  involves  this  danger,  as  well  as  the  possibil- 
ity of  forcing  the  herniated  mass  between  the  abdominal  walls,  or  of 
rupturing  the  gut  at  the  point  where  the  strangulation  existed,  fatal  peri- 
tonitis resulting. 

When  the  slight  risks  of  a  properly  organized  and  conducted  aseptic 
herniotomy,  on  the  one  hand,  are  weighed  against  the  dangers  of  pro- 
longed taxis  on  the  other,  the  argument  is  in  favor  of  a  complete  herni- 
otomy. When  the  advantages  of  a  radical  cure  of  the  hernia  are  added 
to  the  herniotomy  of  necessity,  there  can  scarcely  be  two  opinions  re- 
garding the  gi^eater  desirabihty  of  the  cutting  operation. 

During  herniotomy  the  bowel  has  frequently  been  mistaken  for  the 
hernial  sac,  and  incised.  In  order  to  clear  up  any  doubt  upon  this  point 
the  surgeon  may  press  aside  the  presenting  surface  with  the  1)1  unt  end 
of  a  probe  or  grooved  director.  If  the  bowel  is  presenting,  the  probe 
win  easily  enter  the  peritoneal  cavity ;  but  if  it  is  the  hernial  sac  the 
probe  will  be  arrested  by  the  neck  of  the  sac  at  the  constrictiiig  ring,  or 
at  Poupart's  ligament,  and  cannot  be  made  to  advance  farther  without 
the  employment  of  considerable  force. 

The  diiReulties  of  distinguishing  the  sac  in  umbilical  hernia  are  very 
gi-eatly  increased  by  the  fact  that  this  structure  is  exceedingly  thin  and 
quite  frequently  firmly  attached  to  the  os'erlying  skin. 

Hysterical  Atony  Simulating  Intestinal  Obstruction. — A  case  of 
this  kind  occurred  in  my  service  at  the  Methodist  Episcopal  Hospital  in 
Brooklyn.  The  patient,  a  neurotic  female  of  forty  years  of  age,  had 
been  the  subject  of  increasing  difficulty  of  obtaining  movements  for  a 
year  and  a  haK.  These  were  only  finally  obtained  by  attaching  a  rub- 
ber injection-tube  to  the  house  faucet,  connected  with  one  of  the  general 
city  reservoirs,  and  turning  the  full  force  of  the  pressure  on,  which  was 
estimated  as  not  less  than  twenty  pounds  to  the  square  inch.  This  was 
continued  upon  repeated  occasions  until  the  entire  intestinal  canal  was 
forced  full  of  Avater.  The  method  finally  failed  altogether,  and  she  was 
admitted  to  the  hospital  with  the  abdomen  enormously  distended.  An 
abdominal  section  siiowed  that  no  obstruction  was  present ;  the  entire 
intestinal  tube  was  distended  to  an  enormous  extent. 

The  Cure  of  Hernia  by  Subcutaneous  Injection. — Heaton,  Daven- 
port, and  Warren  have  attempted  the  radical  cure  of  hernia  without  the 
necessity  of  an  operative  procedure,  save  that  involved  in  the  subcutane- 
ous injection  of  fluid  extracts  of  wliite-oak  l)ark.  For  the  same  pnr})0se 
Sehwalbe  has  recommended  the  injection  of  alcohol.  Great  care,  how- 
ever, is  necessary  not  to  pass  the  point  of  the  injecting-needle  into  a  vein. 


SURGICAL   MALPRACTICE.  625 

A  g-la.s8-baiT(>led  syringe  should  be  used.  This  may  be  partially  filled 
"with  the  solution  to  be  injected,  and  introduced  to  the  desired  extent. 
The  piston  may  be  slightly  withdrawn,  when  examination  of  the  contents, 
of  tlie  l)arrel  will  discover  if  a  flow  of  blood  has  ru.shed  into  the  syringe 
to  fill  the  vacuum.  Or  the  ()i)ei-ator  may  pause  for  a  full  minute  after 
introducing  the  needle,  to  sec  if  there  is  a  marked  flow  of  blood  along- 
side the  syringe-point  indicating  that  a  vein  has  been  wounded,  l^efore 
niakiug  the  injection. 

Disturbances  of  Function  Following  Operations  about  the  Lower 
Bowel  and  Anus. — These  disturl)auces  may  consist  in  either  inconti- 
nence of  fivces  and  gas  from  inability  to  contract  the  sphincter,  or  in 
the  presence  of  a  sti'ictnre. 

The  action  of  the  sphincter  may  be  entirely  lost  from  multiple  incis- 
ions across  its  substance  in  fistula  ojjerations,  or  from  failure  of  the 
reparative  process  in  tuberculous  patients  where  but  a  single  incision 
has  been  made.  The  process  of  stretching  the  sphincter,  employed  as  a 
preliminary  step  in  operations  for  the  removal  of  hemorrhoidal  tumors, 
may  also  be  followed  by  degenerative  changes  and  a  more  or  less  per- 
manent weakening  of  the  muscle.  In  addition  to  the  stretching  the  sur- 
geon may  do  still  further  damage  by  including  portions  of  the  nuiscular 
structure  in  the  clamp  or  ligature,  or  by  dissecting  it  away  in  the  opera- 
tion known  as  Whitehead's,  or  some  of  its  modifications. 

Stricture  of  the  rectum  may  result  from  a  too  free  application  of  the 
cautery  in  the  clamp  and  cautery  operation  for  the  removal  of  hemor- 
rhoids. In  both  this  and  the  ligature  operation  the  surgeon  shoidd  be 
carefid  to  leave  well-defined  areas  of  mucous  membrane  between  the 
portions  subjected  to  cauterization  or  included  in  the  ligature.  In  the 
Whitehead  operation,  in  which  the  attempt  is  made  to  excise  the  entire 
so-called  pile-l)earing  area  of  the  rectum,  failure  of  union  if  the  operation 
is  not  properly  performed,  as  well  as  too  great  an  encroachment  upon 
the  cutaneous  surface  of  the  anus,  will  residt  in  stricture  of  the  rectum. 

Ventral  Hernia. — Large  wounds  of  the  abdominal  wall,  whether  op- 
erative or  otherwise,  are  very  liable  to  become  subsequently  the  seat  of 
a  ventral  hernia,  and  reflect  upon  the  care  and  skill  of  the  surgeon.  In 
the  prevention  of  this  distressing  condition  it  is  necessary  to  obtain 
primary  union  of  all  of  the  di^dded  structures,  the  different  layers  being 
united  either  by  buried  sutures,  or  some  form  of  suture  that  will  accom- 
plish the  same  result  and  still  be  capable  of  removal.*  When  the  latter 
is  employed  it  should  be  allowed  to  remain  in  situ  for  at  least  three 
weeks.  A\niatever  method  is  used  the  patient  should  not  leave  the  re- 
cumlient  position  for  four  weeks  at  the  earliest,  some  form  of  external 
bandage  to  support  the  weakened  abdomiual  wall  should  be  worn,  and 
the  patient  cautioned  not  to  engage  in  anj-  \dolent  exercise  for  several 
months. 

THE   GENITO-UEINARY  ORGANS. 

In  no  one  of  the  regions  of  the  body  occur  so  many  surgical  mis- 
haps or  complications,  and  unfortunate  sequelae  to  injuries  and  opera- 
tions, as  in  the  genito-iuinary  system  of  the  male.    Almost  any  accidental 

*  See  article  on  the  "crossed  suture,"  by  the  writer,  in  the  Annals  of  Surgery,  vol. 
XV.,  p.  351. 


626  ^   SYSTEM   OF  LEGAL  MEDICINE.' 

in  jury  or  operative  procedm-e  is  accompanied  hj  accidents,  both  avoid- 
al)le  and  nnavoidable,  and  the  careful  practitioner  who  has  much  to  do 
with  the  surgery  of  these  parts  must  necessarily  be  constantly  watchful, 
lest  his  patient's  life  and  his  own  reiDutation  are  lost  at  one  and  the  same 
time. 

Catheterization. — The  failure  to  thoroughly  disinfect  a  catheter  be- 
fore usiug  it  is  a  most  inexcusable  error,  and  can  only  be  committed  by 
an  ignorant  or  criminally  careless  siu'geon.  Tlie  contention  of  the  great 
French  surgeon  Civiale,  remarkable  from  the  fact  that  it  was  made  long 
before  the  introduction  of  antiseptics,  that  no  person  ever  suffered  from 
■catarrhal  cystitis  in  whose  bladder  a  foreign  body  had  not  been  intro- 
duced, should  be  well  considered  in  this  connection. 

The  making  of  a  false  passage  by  the  unskillful  or  forcible  use  of  a 
metal  catheter  or  sound,  in  the  presence  of  strictui'es  or  enlarged  pros- 
tate, is  one  of  the  most  common  as  well  as  most  culpable  mistakes  in 
sm-gery.  Even  when  the  prostate  has  been  safely  reached  an  attemj)t  to 
bore  through  the  enlarged  middle  lobe  is  sometimes  made,  and  profuse 
hemoiThage,  and  eventually  abscess,  is  the  resiilt. 

The  yoimg  and  inexperienced  surgeon  will  sometimes  fail  in  a  case 
of  retention  to  empty  the  bladder  because  the  instrument  employed  was 
blocked  ujd  ^ly  a  di'ied  blood-clot  or  some  debris  resulting  fi'om  its  last 
jjrevious  use,  Doubt  then  arises  in  the  mind  of  the  operator  as  to,  fli'st, 
whether  or  not  the  instrument  is  in  the  bladder  at  all,  and  secondly, 
whether  the  bladder  contains  any  mine.  To  guard  against  the  possi- 
bility of  such  mistakes  the  catheter  should  be  thorouglily  cleansed  and 
cleared,  and  the  suprapubic  region  j)ercussed  prior  to  the  attempted 
catheterization.  In  paral}'tic  cases  the  uriue  will  sometimes  refuse  to 
flow,  and  in  atony  of  the  bladder  walls  from  prolonged  distention  the 
same  eif  ect  will  be  observed.  Under  these  circumstances  the  doubt  as  to 
whether  or  not  the  catheter  has  been  properly  passed  will  be  cleared  up 
b}^  making  pressure  mth  the  hand  over  the  region  of  the  bladder. 

Warnings  against  the  use  of  cheap  rubber  catheters  cannot  be  too 
often  repeated.  Again  and  again  calculi  ha^^e  been  removed  from  the 
bladder  ha^dng  as  nuclei  pieces  of  a  broken-off  catheter.  Even  a  whole 
soft  rubber  catheter  has  been  found  in  the  bladder,  which  had  slipped  in 
when  the  patient  had  fallen  asleep  after  ha^dng  passed  the  catheter  in 
the  early  hours  of  the  morning  and  retired  again.  Subsequent  search 
failed  to  discover  the  whereabouts  of  the  instrument  until  symptoms  of 
the  presence  of  a  calculus  exj^lained  the  mj^stery. 

In  speaking  of  forced  catheterization  and  the  production  of  false 
passages,  it  was  not  intended  to  convey  the  impression  that  in  competent 
hands  it  is  possible  to  reach  the  bladder  in  aU  cases,  and  without  acci- 
dent. It  is  true  that  if  the  skillful  surgeon  were  to  persist  he  would  do 
as  much  harm  as  the  novice.  The  former,  however,  will  generally  per- 
ceive when  an  unjustifiable  degree  of  force  is  being  employed,  and  desist, 
ha-^-ing  at  his  command  other  means  for  accomplishing  the  desired  object. 
The  ignorant  and  careless  practitioner,  however,  believing  that  he  must 
enter  the  bladder  with  the  catheter  whether  or  no,  proceeds  to  plow  his 
way  through  with  a  metal  instrument,  resrardless  of  consequences. 

Other  Methods  of  Emptying  the  Bladder.— T\nien  the  difficulties  in 
the  way  of  emptying  the  Ijladder,  in  a  case  of  retention  of  urine,  are  such 
as  demand  of  the  prudent  surgeon  the  substitution  of  other  means  than 


SURGICAL   MALPRACTICE.  027 

those  having  for  their  object  the  reaching  of  the  urinary  viscus  by  the 
natural  channel,  the  question  of  the  choice  of  other  methods  of  empty- 
ing the  bladder  will  arise. 

Without  doubt  the  first  choice  at  this  period  will  be  tlie  method  of 
aspiration.  It  should  l)e  borne  in  mind  in  this  connection  that  relief 
of  the  over-distended  viscus  ]>y  aspiration  will  fi-eqnently  i)ermit  of  the 
subscijiieiit  emptying  of  the  latter  l)y  means  of  a  catlieter  through  the 
natural  channel.  The  operation  may  be  done  above  the  pubes  Avithout 
injury  to  the  peritoneum,  and  may  be  repeated  two  or  three  times  in 
twenty-four  hours,  thus  giving  the  patient  relief  until  catheterization  is 
possible  or  other  measures  are  devised  for  his  permanent  rehef. 

The  preference  for  as})iration  over  supra})ul)ie  })uncture  by  a  large 
ti'oear  and  cannula  is  V)ase(l  upon  the  fact  that,  with  the  latter,  urinary 
infiltration  of  the  abdominal  walls  nvAj  occur  aiul  lead  to  serious  phleg- 
monous inflammation  of  these  structures.  Incision  above  the  pubes  may 
be  done  if  the  external  wound  be  made  sufficiently  large  to  permit  of 
ready  escape  of  the  urine ;  but  this  is  an  operation  rarely  performed  for 
retention. 

Permanent  Catheterization. — The  permanent  retention  of  a  catheter 
when  once  the  bladder  has  been  reached  through  the  natural  route  also 
has  its  dangers.  A  metal  instrument  will  rarely  be  tolerated  for  more 
than  a  few  hours,  and  a  soft  rubber  catheter  cannot,  as  a  rule,  be  em- 
ployed in  difficult  catheterization.  Whatever  instrument  is  used,  the 
concentrated  character  of  the  urine  in  these  cases  produces  rapid  in- 
crustation from  the  deposit  of  the  salts,  and  these,  becoming  displaced, 
form  nuclei  for  vesical  calculi. 

Circumcision. — Both  hemorrhage  and  sepsis  follow  this  operation. 
In  the  ritual  operation  the  mohl  or  rabbi  not  infrequently  removes  a 
slice  of  the  glans  also.  In  later  life  the  sear  resulting  from  this  actcident 
may  be  mistaken  foi*  that  whicli  has  followed  a  chancre,  the  i)atient  being 
w^'ongfully  accused  l)ecause  of  its  presence.  In  the  ritual  operation  the 
internal  or  mucous-meml.)rane  surface  of  the  prepuce  is  torn  instead  of 
being  incised,  and  the  rent  thus  made  may  extend,  beyond  the  corona 
glandis  upon  the  dorsum  of  the  penis.  In  France  the  presence  of  a  sur- 
geon is  required  by  law  at  all  ritual  circumcisions. 

Failure  to  keep  the  prepuce  well  retracted  after  the  operation  nuxy 
lead  to  the  formation  of  a  cicatricial  ring  of  the  mucocutaneous  tissues 
about  the  glans  lieyoiul  the  corona  glandis  and  necessitate  a  second 
operation.  This  mishap  may  also  result  from  the  removal  of  an  insuffi- 
cient portion  of  the  prepuce. 

Inexperienced  operators  sometimes  become  alarmed  at  the  swelling 
along  the  suture-line,  and  make  the  attempt  to  remove  still  more  of  the 
prepuce  after  two  or  three  days.  The  result  of  these  attempts  is  usually 
such  as  to  leave  the  parts  in  a  much  worse  condition  than  l)efore.  . 

Hydrocele. — In  the  operation  of  tapping  a  hydrocele  the  nu)st  com- 
mon accident  consists  of  an  injury  to  the  t(*sticle.  Hematocele,  orchitis, 
or  even  abscess,  may  result.  Another  accident  is  the  slii)})ing  of  the 
cannula  from  the  sac  of  the  tunica  vaginalis,  thus  allowing  tlie  contents 
of  the  latter  to  How  into  the  cellular  tissue,  where  it  may  cause  a  phleg- 
mon or  even  terndnate  in  gangrene  of  the  entire  scrotum. 

The  first-named  accidents  arise  from  a  failure  on  the  pai't  of  the  oper- 
.ator  to  bear  in  mind  that  the  testicle  lies  behind  and  upward,  where, 


628  ^   SYSTJEM  OF  LEGAL  MEDLCIXE. 

under  ordinary  cii'cnmstances,  -with  proper  care  it  may  almost  al^rays  be 
avoided. 

It  has  happened  more  than  once  that  the  practitioner  who  is  little 
accustomed  to  operating  and  to  the  care  of  instruments  cleanses  the 
trocar  after  an  operation  and  puts  it  away,  o^-ei'looking  the  cannula. 
When  next  it  is  needed  the  trocar  alone  is  plunged  into  the  hydrocele. 
Again,  it  may  happen  that  he  neglects  to  ascertain  if  the  trocar  can  be 
withdrawn  from  the  cannula.  After  the  puncture  he  essays  to  do  so, 
but  finds  it  so  thoroughly  fastened  by  corrosion  or  rust  to  the  cannula 
that  they  cannot  be  separated. 

Abscess  of  the  Testicle. — Prolapse  of  the  seminiferous  tubules  is  an 
accident  occurring  in  the  course  of  an  abscess  of  the  testicle.  An  ugly,. 
grayish-looking  mass  is  seen  projecting  from  the  abscess  cavity,  which 
the  inexperienced  practitioner  may  mistake  for  an  ordinary  slough,  and 
attempt  to  remove  it  ■with  the  dressing-forceps ;  remo^ang  thus  meter 
after  meter  of  the  tubules  until  several  or  even  all  of  the  lobuli  testes 
are  evacuated,  the  etfeet  being  the  same  as  castration.  Cauterization  of 
the  prolapsed  mass  and  crowding  it  by  means  of  the  dressings  as  much 
as  possible  into  the  lobule  from  which  it  projects,  is  the  proper  treatment. 

Castration. — Separate  ligature  of  the  vessels  of  the  cord,  although 
apparently  a  typical  procedure,  is  less  to  be  relied  upon  than  ligature  en 
masse.  Even  with  the  latter  method,  unless  the  operator  is  careful  tO' 
divide  the  structures  of  the  cord  for  at  least  three  foiu'ths  of  an  inch 
away  from  the  point  of  ligature,  the  action  of  the  cremaster  may  so  re- 
tract the  vessels  as  to  cause  troublesome  hemorrhage.  The  vas  deferens . 
need  not  be  included  in  the  ligatui'e.  In  malignant  disease  of  the  tes- 
ticle and  cord  this  extends  along  the  seminal  duct  proper,  and  recm-reuce 
takes  place  sooner  or  later,  as  a  rule.  A^mlsion  of  the  vas  deferens- 
should  be  done  in  order  to  guard  as  much  as  possible  against  this  result, 
the  vas  being  twisted  and  withdi'awn  at  the  same  time.  In  this  manner 
the  entire  vas  deferens,  from  the  point  where  it  joins  the  ejaculatory  duet 
of  the  corresponding  vesicula  seminalis  at  the  base  of  the  prostate  to 
the  internal  abdominal  ring,  may  be  removed. 

Operations  for  Vesical  Calculus. — All  of  the  operations  for  the  re- 
lief of  stone  in  the  bladder  are  liable  to  some  mishap  or  accident.  While 
the  operation  of  suprapubic  lithotomy  possesses  some  advantages,  par- 
ticularly in  the  removal  of  large  stones  which  cannot  be  crushed,  yet 
there  is  always  great  risk  of  urinary  infiltration  if  the  wound  is  closed 
at  once.  If  it  is  left  open  there  is  less  risk  of  infiltration,  although  im- 
munity from  this  cannot  be  assm-ed  in  any  case ;  yet  the  length  of  time 
required  for  healing  is  such  as  to  severely  tax  the  reparative  powers  of 
the  aged  and  feeble,  in  whom,  unfortunateh',  this  operation  is  called  for 
more  frequently  than  in  the  young  and  vigorous.  In  addition  to  this 
the  dangers  attending  the  use  of  the  rectal  balloon  of  Petersen,  which  is- 
used  to  facilitate  the  elevation  of  the  bladder,  are  to  be  noted.  In  my 
own  experience  the  use  of  the  Petersen  rubber  balloon  resulted  in  a  rupt- 
ure of  the  anterior  wall  of  the  rectum,  although  but  eight  ounces  of 
fluid  were  used  to  distend  it.  {Annals  of  Sim/fri/,  vol.  xii.,  1890,  p.  129.) 
Two  other  cases  are  reported  (Cadge,  P)-oc.  Boijal  Med.  and  Cliir.  iSoc, 
London,  1886,  p.  97;  Nicaise,  quoted  hy  Keyes  in  Annual  of  Universal 
Medical  Sciences.,  1888,  Section  C,  p.  27.)  Median  perineal  lithotomy,  on 
the  other  hand,  admits  of  the  removal  of  moderate-sized  calculi  only,  and 


SUnaiL'AL   MALI'llACTICE.  629 

hence  its  application  in  the  treatment  of  calculous  disease  is  limited. 
The  combination  of  perineal  section  and  lithotrity  (perineal  lithotrity : 
Nussbaum  of  Muiii(,'h,  Doll)eau  of  Paris)  offers  some  advantaj^es,  but  is 
limited  in  its  application.  Lateral  lithotomy,  while  it  admits  of  the  re- 
moval of  a  rather  larg-er  stone  than  the  median  operation,  has  been  ac- 
cused of  causing-  sterility  because  of  injmy  to  the  seminal  vesicles  or  to 
the  ejaculatory  ducts.  Again,  the  rectum  is  more  apt  to  be  injiu-ed  in 
lateral  lithotomy,  particularly  if  tenesmus  and  prolapse  of  the  bowel  have 
been  prominent  features  in  the  histor}-  of  the  case.  Urethro-rectal  fistula 
results. 

In  lithotomy  in  a  number  of  sittings,  as  practiced  previous  to  the 
introduction  of  Bigelow's  metliod  of  lithotomy  at  a  single  sitting  and 
complete  evacuation  of  the  fragments  throng] i  a  large  uretkral  tube 
(litholapaxy),  it  sometimes  happened  that  pointed  fragments  remained  in 
the  bladder  to  torment  the  patient  in  the  intervals  between  the  seances. 
In  addition  to  this  the  surgeon  coidd  never  be  sure  that  all  of  the 
small  fragments  had  been  passed,  and  patients  have  frequenth^  returned 
with  from  four  to  eiglit  stones,  small  fragments  which  had  been  left 
having  served  as  nuclei  of  new  stones. 

Although  these  mishaps  are  prevented  to  a  great  extent  by  the  method 
of  litholapaxy,  together  with  the  use  of  Bigelow's  large  evacuatiiig-tubes 
and  force-pump  apparatus  for  removing  all  fragments  from  the  bladder, 
yet  there  is  one  accident  which  may  occur  in  inexperienced  hands  in  both 
lithotrity  and  litholapaxy.  This  is  the  catching  of  a  fold  of  the  mucous 
membrane  lining  the  bladder  between  the  blades  of  the  crashing  instru- 
ment, and  consequent  injury  to  this  structure.  In  order  to  avoid  this 
the  sui'geon  should  never  forget,  after  having  seized  the  calculus,  to 
rotate  the  instrument  in  order  to  ascertain  whether  or  not  it  mo\'es 
freely  in  the  bladder. 

A  stone  may  be  previously  detected  and  its  presence  verified  by  the 
surgeon's  colleagues,  and  jet  not  be  discoverable  at  the  time  of  the  oper- 
ation. This  is  due  to  the  fact  that  the  stone  is  small  and  falls  into  a 
recess  of  the  bladder,  the  w^alls  of  the  latter  closing  over  it.  In  order  to 
avoid  this  awkward  predicament  it  is  advisable  for  the  surgeon  to  make 
sure  that  the  stone  is  within  reach  just  prior  to  the  administration  of  the 
anaesthetic  at  the  time  of  operation. 

Extravasation  of  Urine. — This  accident  may  follow  the  giving  way 
of  the  urethra  at  a  point  behind  an  old  stricture,  from  long-continued 
pressure  and  the  changes  which  the  mucous  membrane  undergoes  in  con- 
sequence ;  or  it  may  result  from  injuries  to  the  canal,  occurring  from 
the  injudicious  use  of  metal  instruments  in  attempts  at  forced  catheteri- 
zation, and  also  from  lacerated  and  contused  wounds  of  the  perineum 
from  without.  Crush  injuries  of  the  pelvis,  with  fracture  of  the  bones 
of  the  latter,  may  also  be  complicated  with  rupture  of  tlie  urethra  and 
urinary  extravasation.  Fracture  of  the  corpora  cavernosa  during  erec- 
tion, either  from  a  sudden  bending  of  the  peids  by  the  grasp  of  the  hand 
or  ^'iolent  coitus,  likewise  gives  rise  to  this  condition. 

Faihire  to  I'ecognize  the  occurrence  of  extravasation  is  a  grave  error, 
and  is  likely  to  result  in  most  serious  consequences.  In  case  the  solu- 
tion of  continuity  is  behind  the  bull)  this  will  lead  to  infiltration  of  the 
scrotum,  fi'om  Avhich  hx'ality  the  extravasation  will  be  directed  betAveen 
the  spine  of  the  pubes  and  the  symphysis,  finally  reaching  the  abdo- 


G30  ^   SYSTEM  OF  LEGAL  MEDICINE. 

men.  In  tlie  penile  nretlu-a  the  ruptni'e  will  be  followed  by  a  swelling 
of  the  penis,  which  reaches  its  maximiun  in  the  neighborhood  of  the 
point  of  escape.  At  the  membranous  urethra  the  extravasated  urine  is 
confined  between  the  layers  of  the  triangular  ligament,  from  which  it 
subsequently  escajDCS  by  processes  of  sloughing  and  suppuration.  At  the 
prostatic  urethra,  i.e.,  behind  the  posterior  layer  of  the  triangular  liga- 
ment, the  extravasation  may  find  its  way  to  the  anal  region  in  the  peri- 
neum by  following  the  coiu'se  of  the  rectum ;  or  the  thin  pelvic  fascia 
may  give  way  at  its  thinnest  point  near  the  pul^oprostatic  ligament,  thus 
permitting  the  extravasation  to  spread  through  the  subperitoneal  con- 
nective tissue. 

In  whatever  direction  the  urine  finds  its  way,  its  presence  in  the  tis- 
sues gives  rise,  unless  speedy  measui'es  of  relief  by  free  multiple  incisions 
and  thorough  disinfection  of  the  infected  parts  are  instituted,  to  rapid 
sloughing  of  the  connective  tissue,  gangi*ene,  general  sepsis,  and  death. 


APPEISTDIX.* 


EXTEACTS  FKOM  THE  LAWS  OP  THE  DIFFEEENT   STATES  AND   TEEEI- 

TOEIES  OF  THE  UNITED  STATES  WHICH  EELATE  TO  THE 

GENEEAL  CAEE  OF  THE  INSANE. 

The  following  pages  relate  more  particularly  to  the  duties  and  responsibilities  of 
physicians  and  officers  of  the  law  in  reference  to  committing  insane  persons  to  insti- 
tutions for  care  and  treatment,  tlieir  general  management  while  under  treatment,  and 
their  discharge  from  institutions. 

As  the  laws  of  the  States  differ  very  considerably  in  reference  to  the  form  of  pro- 
ceeding necessary  to  be  followed  in  these  several  respects,  it  is  thought  desirable  that 
from  the  great  body  of  statutes  relating  to  the  management  of  the  insane  such  extracts 
as  relate  to  the  duties  of  phj'sicians  slioidd  be  compiled  and  made  easy  for  reference. 
It  is  believed  that  the  following  arrangement  will  prove  to  be  of  service,  especially  to 
general  practitioners. 

Acts  op  Alabama,  1886-87. 

Regulating  the  Admission  and  Discharge  of  Patients  in  the  Alabama  Insane  Hospital. 

Section  1. — Be  it  enacted  by  the  General  Assembly  of  Alabama  that  the  word  "  in- 
sane," where  it  occurs  in  the  act  incorporating  the  Alabama  Insane  Hospital,  shall  be 
construed  to  mean  any  person  who,  by  reason  of  an  unsound  mind,  resulting  from  dis- 
ease of  brain,  is  incapable  of  managing  and  caring  for  his  own  estate  without  danger 
to  himself  or  others  if  permitted  to  go  at  large,  or  is  in  such  condition  of  mind  or 
body  as  to  be  a  tit  subject  for  care  and  treatment  in  the  hospital  for  the  insane  ;  j)ro- 
vided,  that  no  person  idiot  or  imbecile  from  birth,  or  whose  mental  development  was 
arrested  by  disease  or  physical  injury  prior  to  the  age  of  puberty,  or  any  person  who 
is  afflicted  with  simple  epilepsy,  shall  be  regarded  as  insane,  unless  the  manifestation 
of  abnomnal  disability,  ■\dolenee,  homicidal  or  suicidal  impulses  are  such  as  to  render 
his  eoufiinement  in  the  hospital  a  proper  protection  to  prevent  him  from  injiudng  him- 
self or  others. 

Sec.  2. — Be  it  further  enacted  that  authority  to  discharge  patients  from  the  hos- 
pital is  vested  in  the  trustees,  and  may  be  delegated  by  them  to  the  superintendent 
under  such  regulations  as  they  may  see  proper  to  adopt.   .   .   . 

Sec.  3. — Be  it  furtlier  enacted  that  the  superintendent  of  the  hospital  has  author- 
ity to  fui'lough,  for  a  period  not  exceeding  six  months,  such  of  the  harmless  and  con- 
valescent patients  as  in  his  opinion  may  be  benefited  by  the  change.  .  .  .  Proviso  to 
effect  that  expenses  of  furlough  V)e  borne  by  the  parties. 

Sec.  4. — Be  it  further  enacted  tliat  persons  confined  as  insane  shall  be  entitled  to 
the  benefit  of  a  writ  of  habeas  corpus.  .  .  . 

*  This  concise  epitome  of  the  laws  relative  to  the  insane  has  been  made  and  pub- 
lished by  Dr.  H.  P.  Stearns,  and  is  used  with  Ms  kind  permission. 

631 


632  APPENDIX. 

Eevised  Code  of  Alabama,  1886-87. 

Sec.  1237. — Order  of  Admission. 

In  order  of  admission  the  indigent  insane  must  have  precedence  of  the  rich,  and 
recent  cases  of  both  classes  must  have  precedence  over  those  of  long  standing.  The 
paying  patients  from  other  States  may  be  received  into  the  hospital  should  vacancies 
occin-  unclaimed  by  natives  or  residents  of  Alabama. 

Sec.  1241. — Investigation  of  Insanity  and  Admission  to  Hosintal  of  Indigent  Persons. 

"When  a  person  in  indigent  circumstances  becomes  insane,  application  can  be 
made  by  his  friends  or  any  other  person,  in  his  behalf,  to  the  judge  of  the  Probate 
Court  in  the  county  where  he  resides,  and  such  judge  must  without  delay  make  appli- 
cation to  the  superintendent  of  the  hospital  for  his  admission.  .  .  .  "\ATien  informed 
that  the  applicant  can  be  received  the  judge  must  call  one  respectable  physician  and 
other  triistworthy  witnesses  and  fully  investigate  the  facts  in  the  ease,  and  either  with 
or  without  the  verdict  of  a  jury,  at  his  discretion,  must  decide  the  case  as  to  insanity 
and  indigence  ;  and  if  the  judge  believe  that  satisfactory  evidence  has  been  adduced 
showing  the  patient  to  be  insane,  and  his  estate  insufficient  to  siipport  him  and  his 
family  (or  himself  alone,  if  he  has  no  family)  imder  the  visitation  of  insanity,  he 
must,  upon  the  judge's  certificate,  be  consigned  within  thirty  days  to  the  hospital,  at 
the  expense  of  the  county,  and  be  supported  there  at  the  expense  of  the  State ;  and 
the  superintendent  shall  be  required  to  keeji  the  vacancy  for  a  period  of  thirty  days 
after  the  date  of  notice  that  patient  can  be  received.  The  judge  in  all  such  cases 
shall  have  the  requisite  power  to  compel  the  attendance  of  witnesses  and  jiu'ors,  and 
must  file  the  certificate  of  the  physician  and  other  papers  relating  to  the  case,  with  a 
report  of  the  proceedings  and  decision. 

Sec.  1249. —  .  .  .  No  patient  must  be  received  or  discharged  without  suitable 
clothing,  and  if  it  cannot  otherwise  be  obtained  the  steward  must  furnish  it  and 
charge  the  same  to  the  county  from  which  he  was  sent.  The  patient  must  also  be 
furnished  by  the  steward,  if  it  is  not  otherwise  to  be  had,  with  money  sufficient,  not 
to  exceed  twenty  dollars,  to  pay  his  expenses  until  he  reaches  home  ;  and  the  cost  of 
clothing  and  money  advanced  must  have  precedence  over  other  claims,  and  be  repaid 
promptly,  by  the  commissioners  of  the  county  from  which  the  patient  comes,  into  the 
county  treasury. 

Revised  Statutes  of  Arizona,  1887. 
Insane  Persons. 

Paragraph  2156,  Section  1. — 'The  probate  judge  of  any  county  in  this  Territory, 
upon  the  application  under  oath  setting  forth  that  a  person  by  reason  of  insanity  is 
dangerous,  being  at  large,  shall  cause  such  a  person  to  be  brought  before  him  for 
examination,  and  shall  cause  to  be  summoned  to  appear  at  such  examination  two  or 
more  witnesses  acquainted  with  the  accused  at  the  time  of  alleged  insanity,  who  shall 
be  examined  on  oath  as  to  the  conversation,  manners,  and  general  conduct  of  the 
accused  upon  which  «uch  charge  of  insanity  is  based;  and  shall  also  cause  to  appear 
before  him  one  or  more  graduates  of  medicine,  and  known  to  be  reputable  jDracti- 
tioners  thereof,  who  shall  be  present  at  such  examination  and  personally  examine 
accused,  and  shall  set  forth  in  written  statement  to  be  made  by  one  of  them,  first,  his 
or  their  judgment  as  to  the  insanity  of  the  person  charged ;  second,  whether  it  be 
dangerous  to  the  accused,  to  the  person  or  property;  third,  whether  such  insanity  is 
in  his  or  their  opinion  likely  to  prove  permanent  or  only  temporary ;  and  upon  such  a 
hearing  and  statement  as  to  the  aforesaid,  if  the  proofs  shall  satisfy  the  judge  before 
whom  such  hearing  is  had  that  such  party  is  insane,  and  that  by  reason  of  his  or  her 
insanity  he  or  she  be  in  danger,  if  at  liberty,  of  injuring  himself  or  herself,  or  the 
person  or  property  of  others,  he  shall,  by  an  order  entered  by  record  in  a  liook  kept 
for  that  purpose,  direct  the  confinement  of  such  person  in  the  Territorial  Insane 
Asylum,  who  shall  be  confined  therein  and  not  discharged  until  sufficiently  restored 
to  reason. 

Par.  2157,  Sec.  2. — The  principal  supervisors  of  each  county  shall  cause  such. 


APPENDIX.  g:33 

person  to  be  conveyed  to  tlie  Territorial  Insane  Asylum,  and  shall  present  for  tlie 
safe  confinement  and  care  of  such  person  suitable  i)lace  in  such  asylum,  and  shall 
draw  their  warrants  in  payment  of  proper  costs  and  cliarges  tlierefor  upoji  the  county 
treasury ;  and  the  county  treasury  shall  pay  such  warrants  out  of  tlie  general  fund,  as 
other  warrants  are  paid  from  such  fund;  ]>rori(lc(l,  that  such  insane  person  shall  have 
no  money  or  property  from  which  said  cost  and  charges  may  be  paid,  according  to  the 
provision  of  this  act. 

Acts  op  Arkansas,  1889. 
Sec.  1. — Female  AUendunt  to  he  Provided. 

That  all  females  wlio  have  been  adjudged  insane  by  proper  authorities  shall  be 
accompanied  from  the  county-seat,  so  adjudged,  to  the  insane  asylum  by  at  least  one 
female  as  an  attendant  or  protector,  and  the  said  female  attendant  shall  receive  the 
same  compensation  as  is  now  paid  to  male  attendants  for  the  same  service. 

Act  II. 
Sec.  1. — Privileges  of  Inmates  in  Correspondence. 

That  from  and  after  the  passage  of  this  act  each  and  every  inmate  of  each  and 
every  insane  asylum,  either  public  or  private,  in  the  State  of  Arkansas,  shall  be 
allowed  to  choose  one  individual  from  the  outside  world  to  whom  he  or  she  may  write 
when  and  whatever  he  or  she  desires,  and  over  these  letters  to  this  individual  there 
.shall  be  no  censorship  exercised  or  allowed  by  any  of  the  asylum  officials  or  em- 
ployees, but  their  post-office  rights,  so  far  as  this  one  individual  is  concerned,  shall 
be  as  free  and  unrestrained  as  are  tliose  of  any  other  resident  or  citizen  of  the  United 
States,  and  shall  be  under  the  protection  of  the  same  postal  laws  ;  and  each  and  every 
inmate  shall  have  the  right  to  make  a  choice  of  the  individual  party  every  three 
months,  if  he  or  she  so  desire  to  do.  And  it  is  here  made  the  duty  of  the  superintendent 
to  furnish  each  and  every  inmate  of  every  insane  asylum,  either  public  or  private,  in 
the  State  of  Arkansas,  with  suitable  material  for  writing,  inclosing,  sealing,  stamping, 
and  mailing  letters,  sufficient  at  least  for  writing  of  one  letter  per  week,  provided  they 
request  the  same,  unless  they  are  otherwise  furnished  with  such  material,  and  all  such 
letters  shall  be  dropped  by  the  writers  thereof,  accompanied  by  an  attendant  when 
necessary,  into  a  post-office  provided  by  Congress  at  the  insane  asylum  and  kept  in 
some  place  of  easy  access  to  all  patients ;  the  attendant  is  required  in  all  cases  to  see 
that  this  letter  is  directed  to  the  patient's  correspondent,  and  if  it  is  not  so  directed  it 
must  be  held  subject  to  the  superintendent's  disposal ;  and  the  contents  of  these  boxes 
must  be  collected  once  every  week  by  an  authorized  person  from  the  Post-office  De- 
partment, and  by  him  placed'  in  the  hands  of  the  United  States  mail  for  delivery. 

Sec.  2. — Duties  of  Superintoident. 

That  it  is  hereby  made  the  duty  of  the  superintendent  to  keep  registered  and 
posted,  in  some  pviblic  place  at  the  insane  asylum,  a  true  copy  of  the  names  of  every 
individual  chosen,  and  by  whom  chosen,  and  it  is  hereby  made  the  duty  of  the  super- 
intendent to  inform  each  individual  of  the  name  of  the  party  choosing  him  or  her,  and 
he  is  to  request  him  or  her  to  write  his  or  her  own  name  on  the  outside  of  the  envelope 
of  every  letter  he  or  she  writes  to  tliis  individual ;  and  all  these  letters  bearing  the 
individual  writer's  name  on  the  outside  he  is  required  to  deliver,  without  opening  or 
reading  the  same,  or  allowing  it  to  be  opened  or  read,  unless  there  is  reason  for  believ- 
ing the  letter  contains  some  foreign  substance  which  might  be  used  for  medication,  in 
which  case  the  letter  shall  be  required  to  be  opened  in  the  presence  of  a  competent 
witness,  and  this  substance  shall  be  delivered  as  directed. 

Sec.  3. —  Violation  of  the  Act  hij  Persons  Connected  with  Jsj/lnms  a  Misdemeanor. 

That 
violating 

upon  conviction  thereof  sluiJl  he  pui 
■describes  for  misdemeanor,  and  by  ineligibility  to  any  office  in  the  asylum  afterward. 


634  APPENDIX. 


Sec.  4. — Copy  of  this  Act  to  he  Posted  in  Wards  of  the  Asylum. 

That  a  printed  copy  of  this  act  shall  be  kept  posted  in  every  ward  in  every  asylum,, 
both  public  and  private,  in  the  State  of  Arkansas. 


Digest  op  the  Statutes  of  Arkansas,  1884. 

Sec.  3811. — Lunatic  Previously  Mad  may  be  Confined. 

If  any  person  who  has  been  previously  mad,  or  so  far  disordered  in  his  mind  as  to- 
endanger  his  own  person  or  the  person  or  property  of  others,  shall  again  become  in- 
sane, it  shall  be  the  duty  of  his  guardian  or  person  under  whose  care  he  may  be,  and 
who  is  bound  to  provide  for  his  support,  to  confine  him  in  some  suitable  place  imtil 
the  next  term  of  the  Probate  Court  for  his  county,  which  shall  make  such  order  for 
the  restraint,  support,  and  safe-keej)ing  of  such  person  as  the  circumstances  of  the 
case  shall  require. 

Sec.  3812. — Judge  or  Justice  may  Order  Confinement. 

If  any  such  person  of  unsound  mind  as  in  the  last  section  specified  shall  not  be 
confined  by  those  ha'V'ing  charge  of  him,  or  if  there  be  no  person  having  such  charge, 
any  judge  of  a  court  of  record,  or  any  two  justices,  may  employ  any  person  to  confine 
him  in  some  suitable  place  until  the  coui't  shall  make  further  order  thereon,  as  in  the 
preceding  section  specified. 

Sec.  3814. — Insane  Persons  Found  at  Large. 

Insane  persons  found  at  large  and  not  in  the  care  of  some  discreet  person  shall  be 
arrested  by  any  peace  officer  and  taken  before  a  magistrate  of  the  county,  city,  or  town 
in  which  the  arrest  is  made. 


Codes  and  Statutes  of  California,  1886. 

Examination  and  Committal  of  Insane  Persons. 

Sec.  2210. — Examined  before  Whom. 

Whenever  it  appears  by  affidavit  to  the  satisfaction  of  the  magistrate  of  the  county 
that  any  person  within  the  county  is  so  far  disordered  in  his  mind  as  to  endanger 
health,  person,  or  property,  he  must  issue  and  deliver  to  some  officer,  for  ser^sdce,  a 
warrant  directing  that  such  person  be  arrested  and  taken  before  any  judge  of  court 
of  record  within  the  county  for  examination. 

Sec.  2211.— Tico  Witnesses. 

When  the  person  is  taken  before  the  judge  he  must  issue  subpoenas  to  two  or- 
more  witnesses  best  acquainted  with  such  insane  person,  to  appear  and  testify  before 
him  at  such  examination. 

Sec.  2212.— Tm;o  Physicians. 

The  judge  will  also  issue  subpoenas  for  at  least  two  gradu'lates  of  medicine  to 
appear  and  attend  such  examination. 

Sec.  2214. — Diity  of  Physician. 

The  physician  must  hear  such  testimony,  and  must  make  a  personal  examination 
of  the  alleged  insane  person. 

Sec.  2215. — Certificate  of  Physicians. 

The  physicians,  after  hearing  the  testimony  and  making  examination,  must,  if 
they  believe  such  person  to  be  dangerously  insane,  make  a  certificate  showing  as  near 
as  possible  : 

First,  That  such  person  is  so  far  disordered  in  his  mind  as  to  endanger  health,, 
person,  or  property. 


APPENDIX.  G35 

Second,  The  premonitory  symptoms,  apparent  cause,  the  class  of  insanity,  the 
duration  and  condition  of  disease. 

Third,  The  nativity,  age,  residence,  occupation,  and  previous  lial)its  of  the  person. 

Fourth,  The  i>hice  from  whence  the  person  came,  and  the  lengtli  of  his  residence 
in  this  State. 

Sec.  2i!17. — Dutij  of  the  Judge  inid  Clerk  on  Commitment  of  Innanc. 

The  judge,  after  such  examination  and  certificate  made,  if  he  believes  the  person 
so  far  disordered  in  his  mind  as  to  endanger  health,  person,  or  projierty,  must  make 
an  order  that  he  be  confined  in  tlie  insane  asylum.  A  copy  of  such  order  shall  be 
filed  witli  a  record  by  the  clerk  of  the  coimty.  The  clerk  shall  also  keep  in  convenient 
form  an  index-book  showing  name,  age,  and  sex  of  person  so  ordered  to  be  confined 
in  the  insane  asylum,  with  the  date  of  the  order  and  the  name  of  the  insane  asylum 
in  which  the  person  is  ordered  to  be  confined.  No  fees  shall  be  charged  by  the  clerk 
for  performing  any  duties  provided  for  by  this  section. 

Sec.  2222. — Fees  of  PJnjsicians. 

The  physicians  attending  such  examination  of  an  insane  person  are  allowed  five 
dollars,  which  are  to  be  paid  by  the  treasui'er  of  the  county  where  the  examination 
was  had,  on  the  order  of  the  supervisors. 


Code  of  Colorado,  1883. 

2281 — Sec.  28. — (2)  Arrest  of  Various  Lunatics — I)iquest — Verdict — Commitment 

— Custodjj. 

"Whenever  any  reputable  person  shall  file  with  the  county  court  a  complaint,  duly- 
verified,  alleging  that  any  person  is  so  insane  or  distracted  in  mind  as  to  endanger  his 
own  person  or  ju'operty,  or  the  person  or  pi*operty  of  any  other  or  others,  if  allowed 
to  go  at  large,  the  coimty  coui't,  or  judge  thereof,  shall  forthwith  issue  an  order  in  the 
name  of  the  people  direct  to  any  sheriff  or  constable  of  the  county,  for  the  apprehen- 
sion of  such  alleged  insane  person,  which  order  may  be  executed  by  any  sheriff  or  eon- 
stable  of  said  coimty,  or  by  any  person  especially  appointed  by  said  coiu't  to  execute 
the  same  ;  prorided,  that  when  any  sheriff  or  constable  shall  find  within  his  county 
any  such  insane  person  at  large,  it  shall  be  his  duty  to  apprehend  such  insane  person 
without  an  order  of  the  court.  And  when  any  alleged  insane  person  shall  be  an-ested 
by  or  without  an  order  of  the  court,  he  or  she  shall  be  taken  forthwith  before  the 
county  court,  or  judge  thereof,  and  if  the  alleged  insane  person  so  elect,  an  inquest, 
as  provided  for  in  section  1,  shall  be  held  without  delay;  and  until  the  determination 
of  such  inquest  such  alleged  insane  person  shall  be  confined  in  the  county  jail  or  other 
convenient  place.  If  upon  such  inquest  it  shall  be  found  in  the  verdict  of  the  jury 
that  such  alleged  insane  person  is  so  insane  or  distracted  in  mind  as  to  endanger  his 
or  her  own  personal  property,  or  the  person  or  property  of  any  other  or  others,  if 
allowed  to  go  at  large,  it  shall  be  the  duty  of  the  court  to  commit  such  insane  person 
to  the  county  jail  or  other  convenient  place,  to  be  there  confined  until  discharged  on 
inquest  or  otherwise  disposed  of  according  to  law.  .   .  . 

2237— Sec.  34:.— Definition  of  the  Term  "Lunatic" 

The  term  "lunatic,"  as  used  in  this  chapter,  shall  be  construed  to  include  idiots, 
insane  and  distracted  persons,  and  every  person  who,  by  reason  of  intemperance  or 
any  disorder,  or  unsouncbiess  of  mind,  shall  be  incapable  of  managing  and  caring  for 
his  own  estate. 

Sec.  2241. — Superintendent  and  Commissioners  to  Report  AnnuaJJii. 

The  superintendent  of  the  Board  of  Commissioners  shall  make  a  report  to  the 
governor  on  or  before  the  first  day  of  December  in  each  and  every  year,  showing  the 
condition  of  the  asylum  financially,  number,  age,  sex,  occupation,  and  residence, 
treatment  and  state  of  reform  of  persons  admitted,  from  the  date  of  opening  of  the 
asylum  or  from  tlie  date  of  the  last  report,  together  with  siicli  otlier  facts  as  their 
experience  and  observation  may  approve  and  may  deem  in  the  interest  of  tlie  public  ; 
the  governor  shall  cause  such  reports  to  be  published,  and  he  shall  present  them  to 
the  next  general  assembly.   .   .  . 


636  AFFENDIX. 

Acts  of  Connecticut,  1889. 

Chapter  162,  Section  1. — In  this  act  the  words  and  expressions  following  shall 
have  the  several  meanings  hereby  assigned  to  them,  unless  there  is  something  in  the 
subject  or  context  repugnant  to  such  construction.  That  is  to  say,  "asylum"  means 
any  public  or  private  hospital,  retreat,  institution,  house,  or  place  in  which  any  insane 
person  is  received  or  detained  as  a  patient  for  compensation,  but  shall  not  include 
any  ytate-prison,  county  jail,  or  poorhouse,  nor  any  public  reformatory  or  penal  in- 
stitution of  this  State.  "  Insane  person  "  means  and  shall  include  everj^  idiot,  non 
compos,  lunatic,  insane,  and  distracted  person.  "  Patient "  means  any  person  detained 
and  taken  care  of  as  an  insane  person.  The  words  "keeper  of  an  asjdum"  mean  any 
person,  body  of  persons,  or  corporation  who  have  the  immediate  superintendence, 
charge,  management,  and  control  of  an  asylum  and  the  patients  therein.  Words  im- 
porting the  masculine  gender  may  be  applied  to  females. 

Sec.  2.^ — Any  judge  of  a  Proijate  Court,  within  his  probate  district,  shall  have 
power  to  commit  any  insane  person  residing  in  said  district  to  an  asylum  in  this 
State,  in  the  manner  hereinafter  provided. 

Sec.  3. — Except  when  otherwise  specially  provided  by  law,  no  person  shall  be 
committed  or  admitted  to  an  asylum  without  an  order  signed  by  a  judge  of  probate, 
as  hereinafter  provided. 

Sec.  4. — Whenever  any  person  in  this  State  shall  be  insane,  or  s-hall  be  supposed 
to  be  insane,  any  person  may  make  complaint  in  writing  to  any  judge  of  probate 
within  whose  district  the  person  complained  of  shall  reside,  alleging  that  such  person 
is  insane  and  is  a  fit  subject  to  be  confined  in  an  asylum  ;  and  when  any  insane  person 
who  ought  to  be  confined  shall  go  at  large  in  any  town,  any  person  may,  and  the 
selectmen  thereof  shall,  make  a  like  complaint  to  the  judge  of  probate  within  whose 
district  such  town  is  included.  After  receiving  said  complaint,  the  judge  to  whom  it 
is  made  shall  forthwith  appoint  a  time,  not  later  than  ten  days  after  receipt  of  said 
complaint,  and  a  place  within  said  district,  for  a  hearing  upon  said  complaint,  and 
shall  cause  reasonable  notice  thereof  to  be  given  to  said  complainant,  to  the  person 
complained  of,  and  to  such  relative  or  relatives  of  said  person,  or  to  any  person  in- 
terested in  said  person,  as  said  judge  shall  deem  proper,  and  maj^  adjourn  said  heai'- 
ing  from  time  to  time  for  cause.  Said  judge  may  issue  a  warrant  for  the  apprehehsion 
and  bringing  before  him  of  said  person  complained  of,  and  shall  see  and  examine  said 
person,  if  in  his  jiidgment  the  condition  or  conduct  of  such  person  renders  it  necessary 
and  proper  so  to  do,  or  state  in  his  final  order  whj^  it  was  not  deemed  necessary  or 
advisable  so  to  do. 

Sec.  5. — In  addition  to  such  oral  testimony  as  may  be  given  before  such  judge, 
at  said  hearing,  there  shall  be  filed  with  such  judge  a  certificate  signed  by  two  physi- 
cians, each  of  whom  is  a  graduate  of  some  legally  organized  medical  institution  and 
has  practiced  three  years  in  this  State,  and  neither  of  whom  is  connected  with  any 
asylum  nor  related  to  the  person  complained  of  by  blood  or  marriage.  Each  must 
have  personally  examined  said  person  alleged  to  be  insane,  within  five  days  of  signing 
said  certificate,  and  each  shall  certify  that,  in  his  opinion,  said  person  is  insane  and  a 
proper  subject  for  treatment  in  an  asj'lum ;  and  a  copy  of  said  certificate,  attested  by 
said  judge,  shall  be  attached  to  the  final  order  of  said  judge  and  delivered  with  said 
order  to  the  keeper  of  the  asylum  to  which  said  insane  person  shall  be  committed. 

Sec.  6. — If,  on  said  hearing,  the  judge  shall  find  that  the  said  person  is  insane, 
and  a  fit  subject  for  treatment  in  an  asylum,  or  that  he  ought  to  be  confined,  he  shall 
make  an  order  in  writing,  stating  that  lie  so  finds,  and  commanding  some  proper 
officer,  or  auy  fit  person,  to  convey  said  insane  person  to  the  asylum  named  in  said 
order,  unless  some  person  shall  undertake,  before  said  judge,  and  shall  give  bond  to 
the  State  conditioned  to  confine  such  person  in  some  suitable  place  of  detention,  not 
an  asylum,  in  such  manner  as  said  judge  shall  order.   .   .   . 

Sec.  16. — All  insane  persons  confined  in  any  asylum  in  this  State  shall  be  entitled 
to  the  benefits  of  the  ^^ait  of  habeas  corpus,  and  the  question  of  insanity  shall  be 
determined  by  the  court  or  judge  issuing  such  writ,  and  if  the  court  or  judge  before 
whom  such  case  is  brought  shall  decide  that  the  person  is  insane,  such  decision  shall 
be  no  bar  to  the  issuing  of  said  writ  a  second  time,  if  it  shall  be  claimed  that  said 
person  has  been  restored  to  reason.  Said  writ  may  be  applied  for  by  said  iiisane  per- 
son, or  on  his  belialf  by  any  relative  or  friend,  or  person  interested  in  his  welfare. 

Sec.  17. — Tlie  provisions  of  this  act  shall  not  extend  to  nor  affect  in  any  way  the 
cases  of  persons  convicted  of  or  charged  with  crime,  as  provided  for  in  the  following 


Ari'ENDix.  c;J7 

sections  of  the  General  Statutes— to  wit,  sections  IGOO,  IGOl,  1G02,  1003,  3385,  338G, 
3615,  3617,  3618,  3619,  3620,  and  3621  ;  nor  sliall  tliey  be  construed  as  reijealing  sec- 
tions 487,  3683,  and  3684  of  said  (jieneral  Statutes. 

Skc.  18. — The  keeper  of  any  asylum  in  tliis  State  may  receive  and  detain  therein, 
as  a  patient,  any  person  wlio  is  desirous  of  subinittinfj  liiniself  to  treatment  and 
makes  written  application  therefor,  but  wliose  nieiital  condition  is  ncjt  such  as  to  ren- 
der it  legal  to  grant  an  order  of  comniitnient  as  an  insane  jK-rson  in  his  case,  under 
tlie  provisions  of  this  act.  No  such  patient  slmll  be  dctaiued  for  more  tliau  three 
days  after  having  given  notice  in  writing  of  liis  intention  or  desii-e  to  leave  said 
asylum. 

Skc.  19. — An  attorney  at  law  regidarly  retained  by,  or  on  Ijelialf  of,  any  patient  in 
an  asylum,  or  any  medical  practitioner  designated  by  sucli  patient,  or  by  any  member 
•of  his  family,  or  by  some  relative  or  friend  of  such  patient,  sliall  V)e  admitted  to  visit 
such  patient  at  all  reasonable  hours,  if  in  the  opinion  of  tlie  keeper  of  said  asylum 
such  visit  woidd  not  be  injurious  to  said  patient,  or  if  a  judge  of  the  Sui^erior  Court 
first  orders  in  writing  that  such  visit  be  allowed. 

Sec.  20. — All  persons  detained  as  insane  shall  at  all  times  be  furnished  with 
materials  for  connnunicating  with  any  suitable  person  without  the  asj'lum,  and  such 
communications  shall  be  stamped  and  mailed  daily.  Should  the  patient  desire  it,  all 
rational  communications  shall  be  written  at  his  dictation  and  duly  mailed  to  any  rela- 
tive or  person  named  by  the  patient. 

Sec.  22. — All  asylums  in  this  State  sliall  be  subject  to  tlie  inspection  and  visita- 
tion of  tlie  State  Board  of  Charities,  and  shall  be  so  visited  and  inspected  at  least 
once  in  six  months  in  each  year. 

Sec.  23. — Every  person  Avho  willfully  conspii*es  with  any  other  person  unlawfully 
to  commit  to  an  asylum  any  person  who  is  not  insane,  and  any  person  who  shall  will- 
fully and  falsely  certify  to  the  insanity  of  any  person  in  any  certificate  made  and  filed 
as  provided  for  in  this  act,  and  any  person  who  shall  willfully  and  falsely  report  to 
any  court  or  judge  that  any  person  is  insane,  shall  be  ])unished  by  a  fine  not  exceed- 
ing one  thousand  dollars,  or  by  imprisonment  in  the  State-prison  not  exceeding  five 
years,  or  both. 

Sec.  24. — Every  keeper  of  an  asylum  who  shall  willfully  violate  any  of  the  J)ro^^s- 
ions  of  sections  3,  18,  19,  and  20  of  this  act  shall  be  deemed  guilty  of  a  misdemeanor, 
and  may  be  punished  by  a  fine  not  exceeding  two  hundred  dollars,  or  by  imprisonment 
in  a  common  jail  not  exceeding  one  year,  or  both,  at  the  discretion  of  the  court. 

Sec.  25. — All  acts  or  parts  of  acts  inconsistent  herewith  are  hereby  repealed. 


Laws  of  Dakota  Territory,  1887. 
Sec.  2179. — Appointment  of  Co'mmissio)iers  of  Insanity . 

In  each  organized  county  of  this  Territory  there  shall  be  a  board  of  commissioners, 
■consisting  of  three  persons,  to  be  styled  Commissioners  of  Insanity,  two  of  whom  shall 
constitute  a  quorum.   ... 

Sec.  2182. — Duties  of  the  Commissioners  and  tlieir  Power. 

The  said  commissioners  shall  have  cognizance  of  all  applications  for  admission  to 
the  hospital,  or  for  the  safe-keeping  otherwise  of  insane  pei'sous  within  their  respect- 
ive counties,  except  in  eases  otherwise  specially  provided  for.  For  the  purpose  of 
discharging  the  duties  required  of  tliem  thej'  shall  have  the  power  to  issue  subpoenas 
and  compel  obedience  thereto,  to  demonstrate  tliis  and  any  act  of  the  court  necessary 
and  proper  in  the  premises. 

Sec.  2183. — Applieati<»i  for  Admission  to  the  Ilospital. 

Application  for  admission  to  tlie  hospital  must  be  made  in  WTiting,  in  the  nature 
■of  an  information,  verified  by  affidavit.  Sucli  information  must  allege  that  the  person 
on  whose  behalf  ajiplication  is  made  is  believed  by  the  informant  to  be  insane,  and  a 
fit  subject  for  custody  and  treatment  in  the  liospital ;  if  siicli  person  is  found  in  the 
coimty  and  has  a  legal  s(>ttlement  thert>in,  if  such  is  known  to  be  the  fact ;  and  if 
such  settlement  is  not  in  tlie  county,  where  it  is,  if  known,  or  where  it  is  believed  to 
be,  if  the  informant  is  advised  on  the  subject. 


638  APPENDIX. 


Sec.  2184. — Investigation  bi/  Commissioners  as  to  the  Alleged  Insanity — Physician's 

Certificate. 

On  the  filing  of  the  information  as  above  provided  the  commissioners  shall  at  once 
take  steps  to  investigate  the  grounds  of  the  information.  For  this  purpose  they  may 
require  that  the  person  for  whom  such  admission  is  sought  be  brought  before  them, 
and  that  the  examination  be  had  in  his  or  her  presence,  and  they  may  issue  their  war- 
rant therefor  and  provide  for  the  suitable  custody  of  such  person  until  their  investiga- 
tion shall  be  concluded.  .  .  .  Any  citizen  of  the  county,  or  any  friend  of  the  person 
alleged  to  be  insane,  may  appear  and  resist  the  application,  and  the  parties  may  ap- 
pear by  counsel  if  they  elect.  The  commissioners,  whether  they  decide  to  dispense 
with  the  presence  before  them  of  such  person  or  not,  shall  appoint  some  regular  prac- 
ticing physician  of  the  county  to  visit  or  see  such  person  and  make  personal  exam- 
ination touching  the  truth  of  the  allegations  in  the  information  touching  the  actual 
condition  of  such  person,  and  forthwith  rejjort  to  them  thereon.  Such  physician  may 
or  may  not  be  of  their  own  number,  and  the  physician  so  acting  shall  certify,  under 
his  hand,  that  he  has,  in  pursuance  of  his  appointment,  made  careful  personal  exam- 
ination as  required,  and  after  such  examination  he  found  the  person  in  question  in- 
sane, if  such  be  the  fact,  and,  if  otherwise,  not  insane ;  and  in  connection  with  this 
examination  the  said  physician  shall  endeavor  to  obtain  from  the  relatives  of  the  per- 
son in  question,  or  through  other  friends  who  know  the  facts,  correct  answers,  as  far 
as  may  be,  to  the  interrogatories  hereinafter  required  to  be  propoiinded  in  such  cases, 
and  such  interrogations  and  answers  shall  be  attached  to  this  certificate. 

Sec.  2185. — Mow  Patients  should  he  Sent  to  the  Hospital. 

On  the  return  of  the  physician's  certificate  the  commissioners  shall,  as  soon  a& 
practicable,  conclude  their  investigations,  and  having  done  so  they  shall  find  whether 
the  person  alleged  to  be  insane  is  insane;  whether,  if  insane,  a  fit  subject  for  treat- 
ment and  custody  in  the  hospital ;  whether  the  alleged  settlement  of  such  person  is  in 
their  county ;  if  not  in  their  county,  where  it  is,  if  ascertained.  If  they  iind  such  per- 
son is  not  insane  they  shall  order  his  or  her  discharge,  if  in  custody.  If  they  find 
such  person  insane  and  a  fit  subject  for  treatment  and  custody  in  the  hospital,  they 
shall  forthwith  issue  their  warrant  and  a  dui^licate  thereof,  stating  such  a  finding, 
with  the  settlement  of  the  person,  if  found,  and,  if  not  found,  their  information,  if 
any,  in  regard  thereto,  authorizing  the  superintendent  of  the  hospital  to  receive  and 
keep  such  person  therein.  Such  warrant  and  duplicate,  with  the  finding  and  certifi- 
cate of  the  physician,  shall  be  delivered  to  the  sheriff  of  the  county,  who  shall  execute 
the  same  hj  conveying  such  person  to  the  hospital  and  delivering  him  or  her,  with  the- 
duplicate  of  the  physician's  certificate  and  finding,  to  the  superintendent  thereof. 
The  superintendent,  over  his  official  signature,  shall  acknowledge  such  delivery  on  the- 
original  warrant,  which  the  sheriff  shall  return  to  the  clerk  of  the  commissioners,  witk 
his  cost  and  expenses  indorsed  thereon.   .  .  . 

Sec.  2190. — Penalty  for  Cruelty  to  the  Insane. 

Any  person  having  care  of  any  insane  person  and  restraining  such  person,  either 
with  or  without  authority,  who  shall  treat  such  person  with  wanton  severity  or  harsh- 
ness, or  shall  in  any  way  abuse  such  person,  shall  be  guilty  of  a  misdemeanor,  besides 
being  liable  to  an  action  for  damages. 

Sec.  2199. — Postal  Privileges  of  Inmates. 

Henceforth  each  and  every  inmate  of  each  and  every  insane  asylum,  both  public 
and  private,  in  the  Territory  of  Dakota,  shall  be  allowed  to  choose  one  individual 
from  the  outside  world  to  whom  he  may  write  when  or  whatever  he  desires,  and  over 
these  letters  to  this  individual  there  shall  be  no  censorship  exercised  or  allowed  by 
any  asylum  official  or  employee,  but  their  post-office  rights,  so  far  as  this  one  indi- 
vidual is  concerned,  shall  be  as  free  and  unrestricted  as  are  those  of  any  other  resi- 
dent and  citizen  of  the  Territory  of  Dakota,  and  shall  be  under  the  protection  of  the 
same  postal  laws ;  and  each  and  every  inmate  shall  have  the  right  to  make  a  new 
choice  of  this  individual  party  every  three  months  if  he  so  desires  to  do.  And  it  is 
hereby  made  the  duty  of  tlie  superintendent  to  fiu-nish  each  and  every  inmate  of  the 
insane  asylum  in  this  Territory,  either  public  or  private,  with  suitable  material  for 


A  I' VEND IX.  63{> 

writing,  inclosing,  sealing,  stamping,  and  mailing  letters,  snfficient  at  least  for  the 
■writing  of  one  letter  a  week,  iirovidiiig  they  request  the  same,  unless  they  are  other- 
wise furnished  with  such  material,  and  all  such  letters  shall  be  dropped  by  the  writers 
thereof,  accompanied  by  the  attendant  when  necessary,  into  a  post-olHce  box  provided 
at  the  insane  asylum  and  kc})!  in  some  place  easy  of  access  to  all  patients  ;  the  attend- 
ant is  required  in  all  cases  to  see  that  this  letter  is  directed  to  the  patient's  corre- 
spondent, and  if  it  is  not  so  directed  it  must  be  held  subject  to  the  disposal  of  the 
superintendent ;  and  the  contents  of  this  box  shall  be  collected  once  every  week  Ity 
an  authorized  person  of  the  Post-office  Department,  and  by  him  placed  in  the  hands 
of  the  United  States  mail  for  delivery. 

Laws  op  Delaware,  1887. 
Title  60,  Chapter  92,  Section  1. — Proceedings  in  the  Case  of  Indigent  Lunatics. 

Be  it  enacted  (etc.)  that  whenever  the  relatives  or  friends  of  an  indigent  lunatic 
or  insane  person,  a  citizen  of  this  State,  shall  apply  to  the  chancellor  of  this  State, 
either  personally  or  by  petition,  together  with  the  certificate  of  two  practicing  physi- 
cians of  the  county  wherein  such  lunatic  or  insane  person  shall  reside,  one  of  whom 
shall  be  the  regular  physician  of  the  almshouse  of  said  county,  setting  forth  the  facts 
of  said  lunacy  or  insanity,  the  cause  or  causes,  if  known,  and  the  necessity,  in  their 
opinion,  of  a  better  and  more  efficient  mode  of  medical  treatment  in  such  case  than 
can  be  afforded  in  the  almshouse  Avherein  such  lunatic  or  insane  person  may  reside, 
the  chancellor  shall,  if  satisfied  with  the  proofs  offered  of  such  lunacy  or  insanity, 
refer  such  applications  to  the  trustees  of  the  poor  of  said  county  for  information  as  to 
indigency  of  said  person  for  whom  application  is  made,  or  any  other  matter ;  where- 
upon, if  said  reports  be  satisfactory,  the  chancellor  shall  recommend  to  the  governor 
that  such  indigent  lunatic  or  insane  person  be  removed  to  the  Insane  Department  of 
the  New  Castle  County  Almshouse ;  proinded,  that  not  more  than  ten  indigent  lunatic 
or  insane  persons  from  each  of  the  counties  of  Kent  and  Sussex  shall  be  in  said  asylum 
at  the  same  time  ;  and  provided  further,  that  this  shall  not  prevent  the  trustees  of  the 
poor  of  either  county  of  Sussex  or  Kent  from  placing  any  indigent  lunatic  or  insane 
person  that  may  be  placed  in  their  keeping  in  the  said  Insane  Department  of  the  New 
Castle  County  Almshouse  for  whom  no  application  may  be  made,  and  who,  in  their 
opinion,  may  require  special  treatment. 

Sec.  3. — When  Indigent  Lunatics  may  he  Bcturncd. 

That  whenever  the  principal  physician  of  the  Insane  Department  of  the  New 
Castle  County  Almshouse  shall  represent  to  the  trustees  of  the  poor  of  the  county  from 
which  said  indigent  lunatic  or  insane  person  may  have  been  entered  that  any  such 
person  has  been  cured  by  the  treatment  prescribed,  or  they  are  so  far  benefited  and 
improved  in  condition  as  to  render  his  or  her  further  residence  in  said  Insane  Depart- 
ment iranecessary,  or  that  the  said  person  is,  after  full  and  sufficient  opportimity, 
incurable,  then  he  or  she  shall,  upon  the  written  request  of  said  Insane  Department, 
if  cured  or  relieved  as  aforesaid,  be  discharged  from  said  institution  ;  or  if  incurable 
as  aforesaid,  be  returned  to  the  almshouse  for  cure  and  confinement. 

Laws  of  Delaware,  1889. 

Chapter  553,  Section  9. — In  all  cases  of  application  for  the  commitment  of  an 
insane  person  to  the  hospital  the  evidence  and  certificate  of  at  least  two  respectable 
physicians,  based  upon  due  inquiry  and  personal  examination  of  the  person  to  whom 
insanity  is  imputed,  shall  be  required  to  establish  the  fact  of  insanity,  and  a  certified 
copy  of  the  physician's  certificate  shall  accompany  the  person  to  be  committed,  to- 
gether with  the  written  order  of  the  trustees  or  chancellor,  as  provided  in  section  6 
of  this  act. 

Digest,  Laavs  of  Florida,  1881. 

Chapter  147. — Lunatics. 

Sec.  3. — Duty  of  the  Circuit  Judge. 

"Whenever  it  shall  be  suggested,  by  petition  or  otherwise,  to  any  jiidge  of  the  Cir- 
cuit Court  of  this  State  that  there  is  any  lunatic  or  insane  person  within  the  limits  of 
the  judicial  circuit  of  said  judge  incapable  of  managing  his  or  her  o\\^  affairs,  or  of 


■640  ArrE2\Dix. 

taking  care  of  himself  or  herself,  it  shall  be  the  duty  of  said  judge  to  issue  a  writ  to 
the  sheriff  of  the  county  wherein  such  lunatic  or  insane  person  is  alleged  to  be,  direct- 
ing him  to  bring  such  person  before  him  for  the  purpose  of  inquiring  into  the  alleged 
lunacy  or  insanity. 

Sec.  4. — If  it  is  found  upon  investigation  that  such  person  is  a  lunatic  or  insane, 
the  judge  shall  pass  such  order  or  decree  as  is  usually  necessary  in  such  cases. 

Sec.  6. — Order  for  Lunatic  to  he  Taken  to  the  Asylum — Order  for  Private  Care  of  Lunatic. 

If  it  shall  appear  that  said  lunatic  or  insane  person  is  destitute,  then  the  judge 
shall  draw  an  order  that  the  sheriff  shall  transport  such  lunatic  or  insane  person  to 
the  Asylum  for  the  Indigent  Limatics  of  the  State  of  Florida,  and  there  deliver  the 
lunatic  or  insane  person  to  the  officer  having  charge  of  same,  for  the  pin-pose  of  his 
care,  custody,  and  treatment ;  provided,  however,  that  the  judge  may,  in  his  discretion, 
direct  the  said  lunatic  or  insane  person  to  be  delivered  to  any  other  person  for  his 
care,  custody,  and  maintenance,  in  which  event  the  said  insane  person  shall  be  so 
delivered,  and  it  shall  be  the  duty  of  the  person  to  whom  such  delivery  is  made  to 
provide  for  his  care,  custody,  and  maintenance.   .   .   . 

Sec.  12. — Care  of  Lunatics  for  Pay. 

It  shall  be  lawful  for  the  physician  in  charge  of  the  Asylum  for  Indigent  Lunatics 
of  the  State  of  Florida,  when  directed  by  the  Board  of  Commissioners  of  State  Institu- 
tions, to  receive  into  said  asylum  any  lunatic,  idiot,  or  insane  person  whose  fi'iends, 
parents,  or  guardians  are  able  and  willing  to  pay  for  the  care  and  custody  and  main- 
tenance of  said  lunatic,  idiot,  or  insane  person. 

Sec.  13. — Attention,  etc. 

Such  lunatic,  idiot,  or  insane  person  shall  receive  all  care,  food,  clothing,,  and 
medical  attention  as  he  or  she  may  demand  and  require,  from  the  physician  and  other 
employees  of  the  asylum. 

Sec.  17. — Powers. 

The  physician  of  the  asj^lum  shall  have  sole  supervision  of  and  immediate  super- 
intendence of  the  Asylum  for  Indigent  Lunatics  of  the  State,  subject  to  the  direction 
of  the  Board  of  Commissioners  of  State  Institutions. 

Sec.  19. — Physician. 

The  physician  of  the  State-prison  shall  also  be  the  physician  for  such  asylum,  and 
shall  exercise  such  powers,  in  the  matter  of  care  of  the  inmates  of  such  asylum,  as 
may  be  prescribed  by  said  Board  of  Commissioners. 


Acts  of  Floeida,  1887. 

Chapter  3706,  Section  1. — Physicians  of  Asylum  to  Keep  Record  of  Patients,  etc. 

That  it  shall  be  the  duty  of  the  physician  in  charge  of  the  insane  asylum  of  this 
State  to  thoroughly  investigate  the  history  of  patients,  and  upon  careful  diagnosis  of 
same  make  a  record  thereof  in  a  book  of  sufficient  magnitude,  which  book  shall  be 
termed  the  "  Physician's  Book  of  Record  " ;  and  such  record  shall  contain  the  name  of 
each  person  who  may  thus  come  imder  his  treatment,  the  name  of  the  disease  to  be 
treated  and  the  date  of  beginning  treatment,  and  each  day's  prescriptions  while  under 
treatment ;  which  record  shall  be  open  for  future  reference  by  his  successor,  the  cabinet 
officers,  legislative  committees,  and  all  others  interested. 

Acts  op  1883. 

Chapter  3444,  Section  1. — Fee  and  Mileage. 

That  hereafter  any  practicing  physician  who  shall  be  called  in  by  the  circuit  judge 
to  testify  on  an  investigation  as  to  lunacy  or  insanity  of  an  indigent  person  who  shall 
be  alleged  to  be  a  lunatic  or  insane  shall  be  paid  the  sum  of  five  dollars  and  ten  cents 


AI'PENDIX.  G41 

per  mile  by  the  State,  out  of  appropri<ations  for  the  maintenance  of  indigent  lunatics 
and  insane  persons ;  the  same  shall  be  audited  by  the  comptroller  on  the  approval  of 
the  circuit  judge,  and  paid  by  the  treasurer  on  the  comptroller's  wairant. 

Code  of  State  of  Georgia,  1882. 

Sec.  331  (5). — The  State  asylum  is  intended  for  the  care  of  lunatics,  idiots,  epi- 
leptics, or  demented  inebriates.  Inmates  are  divided  into  four  classes :  (1)  Pay  or 
pauper  patients,  residents  of  the  State.  (2)  Pay-patients  who  are  non-residents. 
(3)  Insane  penitentiary  convicts.  (4)  Insane  negroes,  in  certain  cases.  Citizens  of 
Georgia  have  a  i)refevence  over  non-residents. 

Resident  pay-patients  are  admitted  upon  authentic  evidence  of  lunacy  according 
to  law,  or  by  a  certificate  of  three  respectable  physicians  and  two  respectable  citi- 
zens. .  .  . 

Laws  of  1889, 

Providing  for  the  Appointment  of  Guardian  or  Commitment  to  Lunatic  Asylum. 

Sec.  1. — To  have  Guardian  Appointed  or  Subject  Committed  to  Lunatic  Asylum. 

Upon  the  petition  of  a  person  on  oath,  setting  forth  that  another  is  liable  to  have 
a  guardian  appointed  under  the  provision  of  this  act  (or  is  subject  to  be  committed  to 
the  lunatic  asylum  of  this  State),  the  ordinary,  upon  the  proof,  if  ten  days'  notice  of 
siich  application  has  been  given  to  the  three  nearest  adult  relatives  of  such  person, 
or  if  there  is  no  such  relative  within  this  State,  shall  issue  a  commission  direct  to 
any  eighteen  discreet  and  proper  persons,  one  of  whom  shall  be  a  physician,  requiring 
any  twelve  of  them,  including  the  physician,  to  examine  by  inspection  the  person  for 
whom  guardianship  (or  commitment  to  asylum)  is  sought,  and  to  hear  and  examine 
witnesses  on  oath,  to  make  return  of  such  examination  and  inquiry  to  said  ordinarj', 
specifying  in  such  return  under  which  such  classes  they  found  said  person  to  come ; 
such  commission  shall  be  sworn  by  any  of  the  officers  of  this  State  authorized  by  the 
laws  of  this  State  to  administer  an  oath,  "  well "  and  truly  to  execute  said  commission, 
to  the  best  of  their  skill  and  "  ability,"  which  oath  shall  be  retm-ned  with  their  verdict. 

Statutes  op  Idaho,  1887. 

Sec.  750. — The  Idaho  Insane  Asylum,  located  at  Blackfoot,  is  under  the  man- 
agement and  control  of  a  Board  of  Directors,  consisting  of  three  persons.   .   .   . 

Sec.  756. — The  medical  superintendent  must  be  a  gi-aduate  of  medicine,  and  must 
have  practiced  in  his  profession  five  years  after  date  of  his  diploma. 

Sec.  757. — Must  Beside  at  and  Give  his  Entire  Time  to  the  Asylum. 

He  must  reside  at  the  asylum  and  give  his  entire  time  and  attention  to  promote 
the  best  interests  of  the  patients.  His  duties  not  specified  in  this  chapter  must  be 
prescribed  by  the  Board  of  Directors'  by-laws. 

Sec.  758. — General  Powers. 

He  is  the  chief  executive  officer  of  the  asylum,  with  powers  and  duties  as  follows : 
To  control  the  patients,  prescribe  the  treatment,  and  prescribe  and  enforce  the 
sundry  regulations  of  the  asylum. 

Sec.  764. — Discharge. 
Any  person  received  in  the  asylima  must,  upon  recovery,  be  discharged  therefi-om. 

Sec.  767. — Xot  Eligible  for  Admission. 

No  person  laboring  under  any  contagious  or  infectious  disease  must  be  admitted 
into  the  asylum  as  a  patient. 

Sec.  769. — Examination  before  Whom. 

Wlien  it  appears  by  affidavit,  to  the  satisfaction  of  a  magistrate  of  a  county,  that 
any  person  within  the  county  is  so  far  disordered  as  to  endanger  health,  person,  or 


642  APPEXDIX. 

property,  he  must  issue  and  deliver  to  some  peace  officer,  for  service,  a  warrant 
directing  that  sucli  person  be  arrested  and  taken  before  any  judge  of  a  coui't  of  record 
within  the  county  for  examination. 

Sec.  771. — One  Physician. 

The  judge  may  also  issue  subpoenas  for  at  least  one  graduate  of  medicine  to 
appear  and  attend  such  examination. 

Sec.  773. — Duty  of  Physician. 

The  physician  must  hear  such  testimony  and  must  make  a  personal  examination 
of  the  alleged  insane  person. 

Sec.  774. — Certificate  of  Physician. 

The  physician,  after  hearing  the  testimony  and  making  the  examination,  must,  if 
he  believes  the  person  to  be  dangerously  insane,  make  a  certificate  in  his  own  hand- 
wi'iting,  showing,  as  near  as  possible  : 

(1)  That  such  person  is  so  far  disordered  in  his  mind  as  to  endanger  health,  per- 
son, and  property. 

(2)  The  premonitory  symptoms,  apparent  cause  or  class  of  insanity,  and  the  con- 
dition of  the  disease. 

(3)  The  nati^'ity,  age,  residence,  occupation,  and  previous  habits  of  the  person. 

(4)  The  place  from  whence  the  person  came  and  the  length  of  his  residence  in 
this  Territory. 

Sec.  776. — Order  of  the  Judge. 

The  judge,  after  such  examination  and  certificate  made,  if  he  believes  the  person 
so  far  disordered  in  his  mind  as  to  endanger  health,  pei'son,  and  property,  must  make 
an  order  that  he  shall  be  confined  in  the  insane  asylum. 

Sec.  778. — Money  Found  on  Insane  Persons  must  he  Delivered  to  the  Asylum. 

Any  money  found  on  the  person  of  an  insane  person  at  the  time  of  the  arrest 
must  be  certified  to  by  the  judge,  and  sent  with  such  person  to  the  asylum,  there  to 
be  delivered  to  the  medical  superintendent,  who  must  deliver  the  same  to  the  Terri- 
torial treasurer.  If  the  sum  exceed  one  hundred  dollars  the  excess  must  be  applied 
to  the  payment  of  expenses  of  such  person  while  in  the  asylum,  and  delivered  to  the 
person  when  discharged,  or  applied  to  the  pajnuent  of  funeral  expenses  if  the  person 
dies  at  the  asylum. 

Sec.  781. — Fee  of  Physician. 

The  phj'sician  attending  each  examination  of  an  insane  person  is  allowed  five 
dollars,  to  be  paid  by  the  county  treasurer  of  the  county  where  the  examination  was 
had,  on  the  order  of  the  Board  of  Coimty  Commissioners. 


Statutes  of  Illinois,  1881. 

Chapter  85,  page  950. — Lunatics. 

Sec.  1. — Petition. 

That  when  a  person  is  supposed  to  be  insane  or  distracted,  any  near  relative,  or, 
in  case  there  be  none,  any  respectable  person  residing  in  the  coimty,  may  petition 
the  judge  of  the  County  Court  for  proceedings  to  inquire  into  the  alleged  insanity  or 
distraction.  For  the  hearing  of  such  applications  and  proceedings  thereof  the  County 
Court  shall  be  considered  as  always  open. 

Sec.  2.  —  Writ  Service. 

Upon  the  filing  of  such  petition  the  judge  shall  order  the  clerk  of  the  eoiu-t  to  issue 
a  writ,  directed  to  the  sherift'  or  any  constable,  or  the  person  ha^^ng  custody  of  the 
alleged  insane  or  distracted  person,  imless  he  shall  be  brought  before  the  court  with- 
out such  wi'it,  requiring  tlie  alleged  insane  or  distracted  person  to  be  broiight  befoi'e 
him  at  a  time  and  place  to  be  appointed  for  the  hearing  of  the  matter.    It  shall  be  the 


APPENDIX.  G43 

dutj'  of  the  officer  or  person  to  whom  the  writ  is  directed  to  execute  and  return  the 
same  and  bring  the  alleged  insane  person  before  the  court  as  directed  in  the  writ. 

Sec.  4. — Jitrij  Trial. 

At  tlie  time  fixed  for  the  trial  a  jury  of  six  persons,  one  of  wliom  shall  be  a  phy- 
sician, shall  be  impaneled  to  try  tlie  ease.  Tlie  case  shall  be  tried  in  the  presence  of 
the  person  alleged  to  be  insane,  who  shall  have  the  right  to  be  assisted  hy  counsel, 
and  may  challenge  the  jurors  as  in  civil  cases ;  the  court  may  for  good  cause  continue 
the  ease  from  time  to  time. 

Sec.  5. — Verdict. 

After  lieariug  the  e"\ddenee  the  jury  shall  render  their  verdict  in  writing,  signed 
by  them,  which  shall  embody  the  substantial  views  shown  by  the  evidence. 

Sec.  6. — Verdict  Recorded — Order  of  CommitiaJ — JjipJicatiou. 

Upon  the  return  of  the  verdict  the  same  shall  be  recorded  at  large  by  the  clerk, 
and  if  it  appears  that  the  person  is  insane,  and  is  a  fit  person  to  be  sent  to  the  State 
Hospital  for  the  Insane,  the  court  shall  enter  an  order  that  the  insane  person  be  com- 
mitted to  the  State  Hospital  for  the  Insane  ;  and  thereui^on  it  shall  be  the  duty  of  the 
<:'lerk  of  tlie  court  to  make  ajiplication  to  the  superintendent  of  some  of  the  State  hos- 
pitals for  the  insane  for  the  admission  of  such  person. 

Sec.  8. —  Warrant  to  Commit. 

Upon  receiving  notice  at  what  time  the  patient  will  be  received,  the  clerk  shall, 
in  due  season  for  the  conveyance  of  the  person  to  the  hospital  by  the  apijoiiited  time, 
issue  a  warrant  directed  to  the  sherifi"  or  any  other  suitable  person,  pi'eferriug  some 
relative  of  the  insane  person  when  desired,  commanding  him  to  arrest  such  person 
and  convey  liim  to  the  hospital ;  and  if  the  clerk  is  satisfied  that  it  is  necessary,  he 
may  authorize  an  assistant  to  be  employed. 

Sec.  18. — Discharge  of  Patients — Notice — Bemoral. 

Whenever  the  trustees  shall  order  any  patients  discharged  the  superiutendent 
.shall  at  once  notify  the  clerk  of  the  County  Coiu't  of  the  projier  comity  thereof  (if  tlie 
patient  is  a  pauper  [and  if  not,  shall  notify  all  the  persons  who  signed  the  bonds  re- 
quired in  section  15  of  this  act],  and  request  the  removal  of  the  patient).  If  such  patient 
be  not  removed  within  thirty  days  after  such  notice  is  received,  tlien  the  superintend- 
ent may  return  him  to  the  place  from  whence  he  came,  and  the  reasonable  expense 
thereof  may  be  recovered  by  suit  on  the  bond,  or,  in  ease  of  the  pauper,  sliall  be  paid 
by  the  profit  paid  to  the  county. 

Sec.  20. — Bestoration  to  Reason — Discltarge. 

When  any  patient  shall  be  restored  to  reason  he  shall  have  the  right  to  leave  the 
hospital  at  any  time,  and  if  detained  therein  contrary  to  his  wishes  j^fter  sucli  restora- 
tion, shall  have  the  privilege  and  right  of  habeas  corpus  at  all  times,  either  on  his 
application  or  that  of  any  other  person  in  his  behalf.  If  the  patient  is  discharged  on 
such  wi'it,  and  if  it  shall  appear  that  the  superintendent  has  acted  in  bad  faith  or  neg- 
ligently, the  superintendent  shall  pay  all  the  costs  of  the  proceedings.  Such  superin- 
tendent shall,  moreover,  be  liable  to  civil  action  for  false  imprisonment. 

Sec.  22. — TriaJ  hi/  Jury  Nccessari/. 

No  superintendent  or  other  officer,  or  person  connected  with  either  of  the  State 
liospitals  for  tlie  insane,  or  with  any  other  hospital  or  asylum  for  the  insane  or  dis- 
tracted persons  in  this  State,  shall  receive,  detain,  or  keep  in  custody  at  such  hospital 
or  asylum  any  person  wlio  shall  not  have  been  declared,  insane  by  the  verdict  of  a 
jury,  and  authorized  to  be  confined  liy  the  order  of  a  court  of  competent  jurisdiction; 
and  no  trial  shall  be  had,  questioning  the  sanity  or  insanity  of  any  person  before  any 
judge  or  court,  Mitliout  the  person  being  present  alleged  to  be  insane. 


Q4,4:  AFFENDIX. 

Acts  of  Indiana,  1881. 

Sec.  2835. — Duties  of  the  Trustees. 

The  trastees  shall  be  intrusted  with  the  general  control  and  management  of  the 
hospital.  .  .  . 

Sec.  2837. — Proceedings. 

The  trustees  shall  keep  a  fxill  account  of  their  proceedings  in  a  book  to  be  pro- 
vided for  that  purpose.  The  officers  of  the  institution  shall  make  reports  to  the 
trustees  as  they  may  from  time  to  time  require.  The  superintendent  and  treasm-er 
shall  severally  make  full  reports  to  be  submitted  at  their  annual  meetings. 

Sec.  28-10. — Powers  and  Duties. 

The  superintendent  shall  be  the  chief  executive  officer  of  the  hospital,  and  shall 
have  the  care  and  control  of  everything  connected  therewith.  He  shall  see  that  the 
several  officers  of  the  institution  faithfully  and  diligently  discharge  their  respective 
duties.  He  shall  employ  such  attendants,  nurses,  servants,  and  other  persons  he  may 
think  proper,  and  assign  them  to  their  duties,  and  may  at  pleasure  discharge  them. 
He  shall  receive  from  the  proper  persons  the  patients  entitled  to  admission  in  the 
hospital,  and  when  cured  discharge  them.  In  all  cases,  however,  he  shall  be  subject 
to  the  control  of  the  trustees. 

Sec.  2S4:1.—Pe2wrts. 

The  superintendent  shall  make  reports  to  the  trustees  as  required  by  section  2837. 

Sec.  2842. — Admission  of  Patients. 

All  insane  persons  residing  in  the  State  of  Indiana,  and  ha-^dng  legal  settlement  in 
any  county  therein,  shall  be  entitled  to  be  maintained  and  receive  medical  treatment 
in  the  Indiana  Hospital  for  the  Insane  at  the  expense  of  the  State.  .  .  . 

Sec.  2844. — Examination. 

The  justice  of  the  peace  with  whom  said  statements  shall  have  been  tiled,  together 
with  another  justice  of  the  peace  and  a  respectable  practicing  physician  other  than 
the  medical  attendant  of  the  person  alleged  to  be  insane,  who  shall  be  elected  by  the 
aforesaid  justice  of  the  peace,  and  who  shall  reside  in  the  proper  county,  shall  imme- 
diately thereupon  visit  and  examine  the  person  alleged  to  be  insane,  in  relation  to  his 
mental  condition. 

Sec.  2847. — Medical  Certificate. 

They  shall  require  the  medical  attendant  to  make,  on  oath,  a  written  statement  of 
the  medical  history  and  treatment  given  to  the  case. 

Sec.  2852. — Superintendenfs  Duties. 

Upon  receiving  said  application  and  transcribed  statements  and  certificates,  the 
superintendent  of  the  hospital  for  the  insane  shall  immediately,  upon  the  information 
therein  contained,  determine  whether  the  case  is  recent  and  presumably  curable,  or 
chronic  and  less  curable,  or  idiotic  and  incurable.  If  the  case  be  recent  and  curable, 
the  superintendent  shall  at  once  notify  the  proper  clerk  of  the  acceptance  of  the 
application  for  admission.  If  the  case  be  chronic,  whether  cm-able  or  incin-able.  an 
acceptance  shall  issue  as  above,  provided  that  there  be  room  in  the  hospital  for  more 
patients  than  are  at  preseut  resident  therein,  together  with  those  recently  accepted 
but  not  admitted;  otherwise  the  application  shall  be  rejected.  In  the  selection  of 
chronic  eases  for  admission,  each  county  shall  be  entitled  to  a  just  proportion,  accord- 
ing to  its  population,  and  priority  of  application  shall  have  recognition. 

Sec.  2862. — Becurrence  of  Insanity. 

Any  person  who  has  ever  been  adjudged  insane  according  to  law,  within  the 
State  of  Indiana,  and  has  been  formally  discharged  from  any  hospital  or  asylum  for 


APPENDIX.  645 

tlie  insane  within  the  State,  shall  not  again  be  admitted  to  any  such  hospital  or  asy- 
lum, "except  upon  the  affidavit  of  a  respectable  practicing  physician  of  the  county 
where  tlie  patient  resides,  that  he  knows  the  patient,  that  lie  has  been  adjudged 
insane,  that  he  has  been  in  a  hospital,  that  he  is  insane  and  a  proper  subject  for 
treatment."    He  must  state  the  reasons  of  his  opinion. 

Sec.  2m2.—Di!idiurgc. 

Any  patient  may  l)o  discliarged  from  the  hospital  by  the  superintendent  upon 
restoration  to  health;  and  incurMl)l('  and  liarmless  jjatieuts  shall  be  discharged  when- 
ever it  is  necessary  to  mak(^  room  for  recent  cases.  All  dangerous  patients  shall  be 
retained  in  the  hosijital. 

Code  of  Iowa,  1889. 

Sec.  139.5. — In  each  county  there  shall  be  a  board  of  three  Commissioners  of 
Insanity ;  the  clerk  of  the  Circuit  Com-t  shall  be  a  member  of  such  board  and  clerk  of 
the  same  ;  the  other  members  shall  be  appointed  by  the  judge  of  said  com*t.  One  of 
them  shall  be  a  respectable  practicing  physician,  and  the  other  a  respectable  prac- 
ticing lawyer.   .   .   . 

Sec.  i;j99. — Application  for  admission  to  the  hospital  must  be  made  in  the  form 
of  information,  verified  by  affidavit,  alleging  that  the  person  in  whose  behalf  the  appU- 
catiou  is  made  is  believed  by  the  informant  to  be  insane  and  a  fit  subject  for  custody 
and  treatment  in  the  hospital ;  tlnit  such  person  is  found  in  the  county  and  has  a  legal 
settlement  therein,  if  such  is  known  to  be  the  fact ;  and  if  such  settlement  is  not  in. 
the  county,  where  it  is,  if  known,  or  where  it  is  believed  to  be,  if  the  informant  has 
advice  on  the  subject. 

Sec.  1400. — On  the  filing  of  such  information  the  commissioners  may  examine  the 
informant  under  oalh,  and  if  satisfied  there  is  reasonable  cause  therefor  shall  investi- 
gate the  ground  thereof,  and  for  this  purpose  they  may  require  that  the  person  for 
wliom  admission  is  sought  be  brought  before  them  and  that  the  examination  be  had 
in  his  presence  ;  and  they  may  issue  their  warrant  therefor,  and  pro^^de  for  the  suit- 
able custody  of  such  person  until  their  investigation  shall  be  concluded.  Such  war- 
rant may  be  executed  by  the  sheriff  or  any  constable  of  the  county ;  or  if  they  shall 
bf>  of  tlie  opinion  from  such  preliminary  incpiiries  as  they  may  make — and  in  making 
which  they  shall  take  the  testimony  of  the  informant,  if  they  deem  it  necessary  or 
desirable,  and  of  other  witnesses,  if  offered — that  such  course  would  probably  be  in- 
jurious to  such  person,  or  attended  with  no  advantage,  they  may  dispense  with  such 
l)erson.  In  their  examination  they  shall  hear  testimony  for  and  against  such  applica- 
1ion,  if  any  is  offered.  Any  citizen  of  the  county,  or  any  relative  of  the  person  alleged 
to  be  insane,  may  appear  and  resist  tlie  application,  and  the  parties  may  appear  by 
counsel  if  they  elect.  The  commissioners,  whether  they  dispense  with  the  presence 
before  them  of  such  person  or  not,  shall  appoint  some  regularly  practicing  physician 
of  the  county  to  visit  such  person  and  make  a  personal  examination  touching  the 
truth  of  the  information  and  the  mental  condition  of  such  person,  and  forthwith  report 
to  them  theroon.  Such  physician  may  or  may  not  be  one  of  their  own  number ;  and 
the  physician  so  appointed  and  acting  shall  certify,  under  his  hand,  that  he  lias  in 
pursuance  of  his  appointment  made  a  careful  personal  examination  as  required,  and 
that  on  such  examination  he  finds  tlie  person  in  question  insane,  if  such  is  the  fact ; 
and,  if  otherwise,  not  insane  ;  and  in  connection  with  his  examination  the  said  physi- 
cian shall  eiideavor  to  obtain  from  the  relatives  of  the  person  in  question,  or  from 
others  who  know  the  facts,  correct  answers,  as  far  as  may  be.  to  the  interrogatories 
hereinafter  required  to  be  ])i'opounded  in  such  cases  ;  such  interrogatories  and  answers 
to  be  attached  to  his  certificate. 

Sec.  1401. — On  return  of  tlie  physician's  certificate  the  commissioners  shall,  as 
soon  as  practicable,  conclude  tlieir  investigation,  and  shall  fiml  wliether  the  person 
alleged  to  be  insane  is  insane ;  whether,  if  insane,  a  fit  subject  for  treatment  and  cus- 
tody in  the  hospital ;  whether  the  alleged  settlement  of  such  person  is  in  their  county, 
and,  if  not  in  tlieir  county,  where  it  is,  if  ascertained.  If  tliey  find  that  sucli  person 
is  not  insane  they  shall  order  liis  immediate  discharge,  if  in  custody.  If  they  find  such 
person  insane  and  a  fit  subject  for  custody  and  treatment  in  the  hospital  (they  sliall 
order  said  person  to  be  committed  to  the  hospital,  unless  said  person  so  found  to  be 
insane  [or  some  one  in  his  or  her  behalf]  shall  appeal  from  the  finding  of  the  said 
commissioners)  they  shall   forthwith  issue  their  warrant  and  a  duplicate  thereof^ 


646  APFEXDIX. 

stating  siie]i  finding,  witli  the  settlement  of  the  person,  if  found ;  and,  if  not  found, 
theii"  information,  if  any,  in  regard  thereto,  authorizing  the  superintendent  of  the 
hosxjital  to  receive  and  keej)  such  i^erson  as  a  patient  therein  :  such  warrant  and 
duj)licate,  "with  the  certificate  and  finding  of  the  physician,  shall  be  delivered  to  the 
sherrff  of  the  county,  who  shall  execute  the  same  by  conveying  such  person  to  the 
hospital,  and  delivering  him,  with  such  duplicate  and  physician's  certificate  and  find- 
ing, to  the  superintendent  thereof.  .  .  . 

Sec.  1424. — Any  patient  who  is  cured  shall  be  immediately  discharged  by  the 
superintendent.  Upon  such  discharge  the  superintendent  shall  fm-nish  the  patient, 
unless  otherwise  supplied,  with  suitable  clothing  and  a  sum  of  money  not  exceeding 
twenty  dollars,  which  shall  be  charged  with  the  other  expenses  in  the  hospital  of  such 
patient.  The  relatives  of  any  patient  not  susceptible  of  ciu-e  by  remedial  ti'eatment 
in  the  hospital,  and  not  dangerous  to  be  at  large,  shall  have  the  right  to  take  charge 
of  or  remove  such  jDatient  on  consent  of  the  Board  of  Trustees.  In  the  intermediate 
meetings  of  the  board  the  consent  of  two  trustees  shall  be  sufficient. 


G-EXERAL  Statutes  of  Kaxsas,  1889. 

Sec.  260  {Qim).— Government. 

The  government  of  insane  asylimis  of  the  State  shall  be  vested  in  the  Board  of 
Trtistees  of  the  institutions  for  .   .   .  insane. 

Sec.  261  (61S7).—Apj)lication. 

The  Board  of  Trustees  shall  designate  the  superintendent  of  one  of  the  insane 
asylums,  to  whom  all  applications  for  the  admission  of  insane  persons  shall  be  made, 
and  who,  under  such  rules  as  may  be  made  by  the  Board  of  Trustees,  shall  designate 
to  which  asylum  each  applicant  shall  be  admitted.  .  .  . 

Sec.  263  {61S9).— Medical  and  Executive  Officer. 

The  supeiTntendent  shall  be  the  executive  officer  of  the  asylum  and  shall  have 
control  of  all  the  aft'airs  of  the  asylum,  subject  to  the  direction  of  the  Board  of  Trus- 
tees. .  .  .  He  shall  make  to  the  Board  of  Trustees  at  least  semi-annual  reports  show- 
ing the  movements  of  the  population  and  the  operations  of  the  asylum  dui-ing  the 
period  embraced  therein;  and  at  the  close  of  the  biennial  period  he  shall  report  in 
detail  the  conditions  of  the  asylum  and  all  of  its  concerns. 

Sec.  266  (6192). — Abstract  of  Correspondence. 

A  full  absti'act  of  all  correspondence  relating  to  the  admission  of  patients,  their 
treatment,  and  all  other  matters  of  an  official  natui-e  and  the  replies  thereto,  shall  be 
kept  by  the  superintendent.  He  shall  also  cause  to  be  kept  a  complete  record  of  each 
ease  and  the  treatment  thereof,  and  prescription-book,  with  the  date  when  it  was 
appointed  and  administered,  and  such  other  records  as  may  be  necessary  to  give  the 
board  and  the  public  a  ftill  knowledge  of  all  prescriptions  and  business  of  the  medical 
department. 

State  of  Kentucky,  Statutes,  1881. 

Chapter  73,  Section  4. — Officers  of  the  Asylum. 

There  shall  be  for  each  asylum  a  medical  superintendent,  who  shall  be  a  skillful 
physician,  and  a  steward ;  and  for  the  Eastern  Kentucky  Asylum  a  first  and  a  second 
assistant  physician ;  and  for  the  Central  Kentucky  Asylum  one  assistant  physician. 
These  officers  shall  reside  in  the  asylum.  .  .  . 

Sec.  5. — Duties  of  Medical  Superintendent. 

A  medical  superintendent  shall  have  general  management,  supervision,  and  con- 
trol of  patients  and  the  asylum,  subject  to  the  regulations  of  the  Board  of  Commis- 
sioners, and  shall  devote  his  entire  time  thereto.     He  shall  keep  a  register  of  all 


Arj'KXDix.  G47 

patients,  sliowing  their  names,  ages,  residences,  dates  of  reception  and  discharge  or 

death,  by  wliose  antliority  received,  and  whether  they  are  ])ay-patients  or  paupers. 

The  superinteiuleiit  sliall  jii)pi)iut  all  Hueh  other  inferior  oOieers  and  employees 
(not  otherwise  provided  for  in  this  act)  as  he  may  deem  necessary  for  the  proper 
niaiiaj^'ement  of  Hie  institution  ;  and  he  may  remove  any  of  them  at  pleasure  and  till 
tiieir  places  with  others. 

Sec.  9. — I'reiioncc  of  the  Person  Xeccssciri/. 

No  inquest  shall  be  held  unless  the  person  charged  to  be  of  unsound  mind  is  in 
the  court  and  personally  in  the  presence  of  a  jury.  The  personal  presence  of  the 
person  charged  shall  not  be  dispensed  Avitli  xmless  it  shall  appear  by  the  oath  or 
affidavit  of  two  pliysicians  that  they  made  personal  examination  of  the  individual 
charged  to  be  of  unsound  mind,  and  that  they  verily  believe  him  to  be  an  idiot  or 
lunatic,  as  the  ease  may  be,  and  that  his  condition  is  such  that  it  may  be  unsafe  to 
bring  him  into  court. 

Sec.  14. — Discharge  of  Patients. 

No  private  patient  who  has  not  been  found  to  be  insane  by  regular  inquest  shall 
be  received  into  either  of  the  State  asylums.  Nor  shall  any  patient  be  discharged  as 
•cured,  or  delivered  to  the  custody  of  friends,  whose  friends  have  placed  him  in  the 
asylum,  but  by  permit  of  the  superintendent  and  commissioners.  Any  cured  patient 
who  was  committed  to  the  asylum  while  in  custody  of  the  law  upon  a  criminal  charge 
shall  be  delivered  to  the  keeper  of  the  penitentiary  or  to  the  jailer  of  the  county,  as 
the  case  may  require. 

A  ciu'ed  pauper  before  being  discharged  shall  have  a  good  suit  of  clothes  and  be 
furnished  with  money  enough  to  pay  his  ti'aveling  expenses  back  home,  not  exceeding 
twenty  dollars. 

Sec.  20. — Bcjwrt  of  Superintendent  and  Board. 

The  superintendent  and  the  Board  of  Commissioners  shall,  on  or  before  the  1st  of 
November  of  each  year,  make  a  report  to  the  governor  of  the  condition  of  the  asylum 
in  their  charge,  .  .  .  number  and  names  of  patients  (distinguishing  pauper  from  pay 
patients  and  certifying  the  place  from  which  they  came),  the  number  received  and 
discharged  each  year,  with  such  other  facts  and  suggestions  they  may  deem  important, 
which  report  the  governor  shall  communicate  to  the  legislature  at  its  next  regular 
session. 

Statutes  of  Louisiana,  1876. 
Sec.  1768. — Lunatics — Hoiv  Admitted. 

Whenever  it  shall  be  known  to  the  judge  of  a  district  or  parish  court,  by  the  peti- 
tion on  oath  of  any  individual,  that  any  lunatic  or  insane  jierson  within  his  district 
ought  to  be  sent  or  confined  in  the  insane  asylum  of  this  State,  it  shall  be  the  duty  of 
said  district  or  parish  judge  to  issiie  a  warrant  to  bring  before  him  said  lunatic  or  in- 
sane person,  and  after  inquiry  into  all  the  facts  and  circumstances  of  the  case,  if  in 
his  opinion  he  oiight  to  be  sent  or  confined  in  said  asylum,  he  shall  make  out  his  war- 
rant to  the  sheriif  of  the  parish,  commanding  him  to  convey  the  lunatic  or  insane 
person  to  the  insane  asylum.  ... 

Sec.  1776. — Examination  hi/  PJiysician. 

The  physician  of  the  asylum  shall  professionally  examine  the  hmatic  or  insane 
person  sent  to  the  asylum  by  the  authority  of  the  district  or  parish  judge,  and  if  in 
his  opinion  said  person  is  only  feigning  insane,  being  a  person  charged  with  felonious 
crime,  he  shall  report  to  the  board,  who  shall  investigate  the  facts,  and  if  in  the  judg- 
ment of  the  majority  said  person  shall  not  be  admitted  as  an  inmate  of  the  asylum, 
the  president  of  said  board  shall  cause  said  person  feigning  insanity,  and  who  had 
been  previoiisly  committed  to  prison  for  a  crime,  to  be  confnuMl  in  Hie  parish  jail,  and 
shall  immediately  inform  the  president  of  the  police  of  the  parish,  or  a  proper  author- 
it_v  in  the  parish  of  Orleans,  where  the  rejected  person  has  his  domicile,  of  the  fact 
and  the  reason  of  his  rejection ;  and  the  provisions  of  this  section  shall  also  apply  to 
such  persons  charged  with  a  crime  who  afterward  recover  and  become  sane  in  said 
iisvlum. 


(348  APPENDIX. 

Acts  of  Louisiana,  1888. 

Sec.  1. — Postal  Bights  of  Inmates. 

Be  it  enacted  by  tlie  General  Assembly  of  Louisiana,  that  henceforth  each  and 
every  inmate  of  each  and  every  insane  asylum,  both  public  and  private,  in  the  State 
of  Louisiana,  shall  be  allowed  to  choose  one  individual  to  whom  he  or  she  may  write 
when  and  whatever  he  or  she  desires,  and  over  these  letters  to  this  individual  there 
shall  be  no  censorship  exercised  or  allowed  by  any  of  the  asyhun  officials  or  employees, 
but  their  post-office  privileges  shall,  so  far  as  this  one  individual  is  concerned,  he  as 
free  and  unrestricted  as  are  those  of  any  other  resident  or  citizen  of  the  State  of 
Louisiana,  and  shall  be  under  the  protection  of  the  same  postal  laws ;  and  each  and 
every  inmate  shall  have  the  right  to  make  a  new  choice  of  this  individual  every  three 
months  if  he  or  she  so  desires.  And  it  is  here  made  the  duty  of  the  superintendent  to 
fiu'uish  each  and  every  inmate  of  every  insane  asylum  in  this  State,  either  public  oi- 
private,  with  suitable  material  for  writing,  inclosing,  sealing,  stamping,  and  mailing 
letters,  sufficient  at  least  for  the  writing  of  one  letter  a  week,  provided  they  request 
the  same,  unless  they  are  otherwise  furnished  with  such  material ;  and  all  such  letters 
shall  be  dropped  by  the  writer  thereof,  accompanied  by  an  attendant  when  necessary, 
into  a  post-office  box  of  the  State  at  the  insane  asylum  and  kept  in  some  place  easy 
of  access  to  all  patients.  .  .  . 


Statutes  of  Maine,  1883. 

Sec.  1. — Government  of  the  Asylum. 

The  government  of  the  Maine  Insane  Hospital  is  vested  in  a  committee  of  six 
trustees,  one  of  whom  shall  be  a  woman.   .   .  . 

Sec.  4. — TJie  Trustees  may  Examine  and  Discliarge  Patients. 

There  shall  be  a  thorough  examination  of  the  hospital  monthly  by  two  of  the 
trustees,  quarterly  by  three,  and  annually  by  a  majority  of  the  full  board ;  and  at 
any  other  time  when  they  deem  it  necessary  or  the  superintendent  requests  it.  At 
each  visit  a  written  account  of  the  state  of  the  institution  shall  be  drawn  up  by  the 
visitors,  recorded,  and  presented  at  the  annual  meeting  of  the  trustees,  at  which 
meeting  they,  with  the  superintendent,  shall  make  a  particular  examination  of  the 
condition  of  each  patient,  and  discharge  any  one  so  far  restored  that  his  comfort  and 
safety  and  that  of  the  pulalic  no  longer  require  his  confinement.   .   .  . 

Sec.  7. — Duties  and  Powers  of  the  Superintendent. 

The  superintendent  shall  be  the  physician,  reside  constantly  at  the  hospital,  have 
general  superintendence  of  the  hospital  and  grounds,  receive  all  patients  legally  sent 
to  the  hospital,  unless  the  number  exceeds  its  accommodation,  and  have  charge  of 
them,  and  control  of  all  persons  therein,  subject  to  the  regulations  of  the  Board  of 
Trustees ;  and  annually  on  the  last  day  of  November  report  to  the  trustees  the  condi- 
tion and  prospects  of  the  institution,  with  such  remarks  and  suggestions  relative  to 
its  management  and  the  general  subject,  of  interest,  as  he  thinks  will  promote  the 
cause  of  science  and  humanity. 

Sec.  29. — Rules  should  be  Kept  Posted. 

The  superintendent  shall  keep  posted,  in  conspicuous  places  about  said  hospital, 
printed  cards  containing  the  rules  prescribed  for  the  government  of  the  attendants  in 
charge  of  patients. 

Sec.  34. — Certificate  of  Physicians. 

In  the  case  of  preliminary  proceedings  for  the  commitment  of  an  insane  person  to 
the  hospital,  the  evidence  and  certificate  of  at  least  two  respectable  physicians,  based 
upon  due  inquiry  and  personal  examination  of  the  person  to  whom  insanity  is  im- 
puted, shall  be  required  to  establish  the  fact  of  insanity,  and  a  certified  eopj^  of  the 
physicians'  certificate  shall  accompany  the  person  to  be  committed. 


APPENDIX.  G4t) 

Sec.  36. — Postal  Rujlits  of  the  Inmates. 

The  names  of  the  Committee  of  Examiners  and  the  post-office  address  of  each 
shall  he  kept  posted  in  every  ward  of  the  hospital,  and  every  inmate  shall  be  allowed 
to  write  when  and  whatever  he  pleases  to  tlieni,  or  either  of  them,  unless  otherwise 
ordered  by  a  majority  of  the  committee  in  writing,  wliich  order  shall  continue  in  force 
until  countermanded  in  writing  by  said  comnuttee.  For  this  purpose  every  patient 
not  otherwise  ordered  as  aforesaid  shall  be  furnished  by  the  superintendent,  on  re- 
quest, with  suitable  materials  for  writing,  inclosing,  and  sealing  letters.  Tlie  super- 
intendent shall  provide,  at  the  expense  of  the  State,  securely  locked  letter-boxes, 
easily  accessible  to  all  inmates,  to  be  placed  in  the  hospital,  into  wldcli  such  letters 
can  be  dropped  by  the  writer.  No  officer,  attendant,  or  employee  of  the  hospital  shall 
have  tlie  means  of  reaching  the  contents  of  these  boxes,  but  the  letters  in  them  shall 
he  collected  weekly  by  some  member  of  the  committee,  or  by  such  person  as  the  com- 
mittee authorizes  for  the  purpose,  who  shall  prepay  such  only  as  are  addressed  to 
some  of  the  committee,  and  deposit  them  in  the  post-office  without  delay. 

Laws  of  IMaryland,  1888. 

Sec.  1. — When  any  person  is  alleged  to  be  a  lunatic  or  insane,  the  Circiut 
■Court  of  the  county  in  which  such  person  may  reside,  or  a  criminal  court  of  Baltimore 
(if  such  person  reside  in  the  city  of  Baltimore),  shall  cause  a  jiuy  of  twelve  good  and 
lawful  men  to  be  impaneled  forthwith,  and  shall  chai'ge  the  said  jiu-y  to  inquire 
whether  such  jjerson  is  insane  or  lunatic ;  and  if  found  so  it  shall  be  the  duty  of  the 
court  to  cause  such  person  to  be  sent  to  the  almshouse  of  the  county,  or  to  a  hospital, 
■or  to  some  other  place  better  situated,  in  the  judgment  of  the  court,  for  his  condition, 
there  to  be  coniined  at  the  expense  of  the  county  or  State  until  he  shall  recover  and 
be  discharged  in  due  course  of  law.  .   .   . 

Sec.  26. — The  superintendent  or  other  officer  or  keeper  of  any  institution,  public, 
■corporate,  or  private,  or  almshouse,  where  the  insane  may  be  kept,  shall  be  required  to 
keep  a  record  of  all  patients  in  such  form  as  the  commissioners  shall  direct ;  also  a  record 
in  which  shall  be  entered  the  incidents  and  accidents  that  may  occiu- ;  also  the  number 
and  kinds  of  restraints  used,  with  details  of  them,  to  be  reported  to  the  commissioners. 

Sec.  30. — The  Board  of  Managers  or  superintendent  of  any  institution,  public, 
corporate,  or  private,  or  almshouse,  which  may  be  duly  authorized  to  hold  iu  custody 
any  insane  person  in  accordance  with  the  law,  may  appoint  one  or  more  attendants 
or  other  employees  of  such  places,  as  policeman  or  policemen,  whose  duty  it  shall  be, 
under  the  orders  of  said  superintendent  or  manager  or  keeper,  to  arrest  and  return  to 
such  asylum,  or  other  institution  for  the  treatment  of  the  insane,  or  insane  persons 
who  may  escape  therefrom. 

Sec.  31. — No  persou  shall  be  put  or  confined  as  a  patient  in  any  institution,  piib- 
lic,  corporate,  or  private,  or  almshouse,  or  other  house  for  the  care  and  custody  of  the 
insane  or  idiotic,  except  upon  the  rendering  of  a  certificate  of  two  qualified  physicians, 
made  within  one  week  after  the  examination  by  them  of  said  alleged  hmatic,  and  set- 
ting forth  the  insanity  or  idiocy  of  such  person,  and  the  reason  for  such  opinion.   ... 

Sec.  33. — The  superintendent  or  other  officer  of  any  asylum  or  other  institution 
where  the  insane  are  kept  in  custody  or  received  for  treatment,  whether  public,  cor- 
porate, or  private,  or  almshouse,  shall  within  ten  days  after  the  reception  of  such 
patient  or  person  make,  or  cause  to  be  made,  a  description  of  such  case  in  a  book 
kept  exclusively  for  the  purpose ;  they  shall  also  make  entries  from  time  to  time  of 
the  mental  condition  of  such  patient  or  person  so  confined. 

Sec.  35. — Every  person  confined  in  such  place  as  hereinbefore  mentioned  shall  be 
furnished  at  all  times  with  paper,  envelopes,  stamps,  lien  and  ink,  or  pencil ;  shall  at 
all  times  have  access  for  correspondence  with  the  L\macy  Commission,  and  some  one 
other  person  wliom  such  lunatic  may  designate  every  month,  under  seal,  which  com- 
munication shall  be  forAvarded  by  the  officer,  superintendent,  or  keeper  who  may  be  in 
charge  of  such  person  or  place.   ... 

Acts  of  Massachusetts,  1882. 
Chapter  87,  Section  11. — Jitdgcs  may  Commit  Insane  Persons  to  the  State  Hospitol. 

A  judge  of  the  Supreme  Judicial  Court  or  Superior  Court  of  any  coimty,  or  a 

judge  of  a  probate  court,  or  of  a  police  or  district  or  nnmicipal  court  within  this 


650  APFEyDix. 

county,  may  commit  to  either  of  the  State  lunatic  asylums  any  insane  person.  Tvhen 
residing  or  being  in  said  county,  who  in  his  opinion  is  a  proper, subject  for  its  treat- 
ment or  custody. 

Sec.  12. — Xo  Person  to  he  Committed  to  any  Hospital  icithoiit  Order  of  the  Judge. 

Except  when  otherwise  specially  provided,  no  person  shall  be  committed  to  the 
limatic  hospital  or  other  receptacle  for  the  insane,  public  or  private,  without  the 
order  or  eertiiicate  therefor  signed  by  one  of  the  judges  named  in  the  preceding  sec- 
tion, said  person  residing  or  being  within  the  county  as  herein  proAided.  Such  order 
or  certificate  shall  state  that  the  judge  finds  the  person  committed  is  insane  and  is  a 
fit  person  for  the  treatment  of  the  insane  asylum.  The  said  judge  shall  see  and 
examine  the  person  alleged  to  be  insane,  or  state  in  his  final  order  why  he  did  not 
deem  it  necessary  or  advisable  to  do  so.  .   .  . 

Sec.  13. — Certificate  of  two  Fliysicians. 

No  i^erson  shall  be  committed  unless,  in  addition  to  the  formal  testimony,  there 
has  been  filed  with  the  judge  a  certificate  signed  by  two  physicians,  each  one  of  whom 
is  a  graduate  of  some  legallj^  organized  medieal  college  and  has  practiced  three  years 
in  the  State,  and  neither  of  whom  is  connected  with  any  hospital  or  other  establish- 
ment for  treatment  of  the  insane.  Each  must  have  personally  examined  the  person 
alleged  to  be  insane  "n^ithin  five  days  of  signing  the  certificate,  and  each  shall  certify 
that  in  his  opinion  said  person  is  insane  and  a  j^roper  subject  for  treatment  in  the 
insane  hospital,  and  shall  specify  the  facts  on  which  his  opinion  is  formed.  A  copy 
of  the  certificate,  attested  by  the  judge,  shall  be  delivered  by  the  oflicer  or  other 
person  making  the  commitment  to  the  superintendent  of  the  hospital  or  other  place 
of  commitment,  and  shall  be  filed  and  kept  with  the  order. 

Sec.   15. — Statement  regarding  Insane  Person  to  be  Filed  icitJi  the  Judge — Duty  of  the 

Superintendent. 

Upon  every  application  for  the  commitment  or  admission  of  any  insane  person  to 
a  hospital  or  asylum  for  the  insane  there  shall  be  filed  with  the  api:ilication,  within, 
ten  days  after  the  commitment  or  admission,  a  statement  in  respect  to  such  person, 
showing,  as  near  as  can  be  ascertained,  his  age,  birthplace,  exact  condition,  place, 
and  occupation ;  the  supposed  cause  and  duration  and  character  of  his  condition, 
whether  mild,  Adolent,  dangerous,  homicidal,  suicidal,  parahi:ic,  apoplectic ;  the 
present  symptoms  of  insanity  in  the  person  or  his  family ;  his  habits  in  regard  to  tem- 
perance ;  whether  he  has  been  in  a  limatie  asylum  or  hospital,  and,  if  so,  what  one, 
when,  how  long;  and,  if  the  patient  is  a  woman,  whether  she  has  borne  children, 
and,  if  so,  what  time  had  elapsed  since  the  buth  of  the  youngest ;  the  names  and 
addresses  of  his  father,  mother,  children,  brother,  sister,  or  others  next  of  kin,  not 
exceeding  ten  in  number  and  over  eighteen  years  of  age,  when  the  names  and 
addresses  of  such  relatives  are  known  by  the  person  or  persons  making  such  applica- 
tion, together  with  any  fact  showing  whether  he  has  or  has  not  a  settlement,  and.  if 
he  has  a  settlement,  in  what  place ;  and  if  the  applicant  is  unable  to  state  any  of  the 
above  particulars  he  shall  state  his  inability  to  do  so.  The  statement,  or  a  copy 
thereof,  shall  be  transmitted  to  the  superintendent  of  the  hospital  or  asylum,  to  be 
filed  with  the  order  or  application  for  admission.  The  superintendent  shall,  within 
two  days  of  the  time  of  admission  or  commitment  of  the  insane  person,  send,  or  cause 
to  be  sent,  notice  of  said  commitment,  in  wi-iting,  by  mail,  postage  prepaid,  to  each 
of  said  relatives,  and  to  any  other  two  persons  whom  the  person  committed  shall 
designate. 

Sec.  26. — Persons  Violently  Insane  may  he  Bcceived  at  the  Hospital  without  Warrant  of 

Commitment. 

The  superintendent  or  keeper  of  a  hospital,  including  the  McLean  Asylum  at 
SomerAdlle,  may  receive  into  his  custody,  and  detain  in  such  hospital  or  asylum  for  a 
period  not  exceeding  five  days,  without  an  order  of  the  judge  as  provided  in  section 
2,  any  person  as  insane  whose  case  is  duly  certified  to  be  one  of  violent  and  dangerous 
insanity  and  emergency  by  two  physicians  qualified  as  in  section  13.  In  addition  to 
such  certificates  an  application  signed  by  one  of  the  selectmen  of  the  town,  or  by  one 
of  the  aldermen  of  the  city,  in  which  such  insane  person  resides  or  is  found,  shall  be 
left  with  the  superintendent  of  the  hospital  or  asylum  in  Avhich  the  insane  person  is 


APPENDIX.  CGI 

received,  and  sTich  application  shall  contain  tli(>  statement  in  respect  to  such  insane 
person  vvliicli  is  required  by  section  15,  and  a  further  statement  that  the  case  is  one  of 
violent  and  dangerous  insanity. 

Skc.  -9. — Xotice  U)  be  (Uroi  to  llic  Bodvd  of  IlcalUi,  LiiitKcii,  <ih<1  ClutrUij. 

Wlieu  the  patient  is  received  into  such  hosi)ital  upon  his  own  application  or  under 
the  provisions  of  section  26,  the  superintendent  thereof  shall  j^ive  immediate  notice 
of  such  reception  to  the  States  Board  of  Health,  Lunacy,  and  Chai'ity,  stating  all  the 
particulars,  including  tlio  legal  settlement  of  the  person  so  received,  if  known;  the 
State  board  shall  immediately  cause  such  eases  to  be  investigated  and  a  record  V^e 
made  of  all  the  facts  pertaining  thereto. 

Sec.  35. — Certain.  Privileges  of  Patients  in  Hos})itals. 

An  attorney  regularly  retained  by  or  on  behalf  of  any  person  committed  to  a 
lunatic  hospital,  asylum,  or  receptacle  for  the  insane  shall  be  admitted  to  visit  such, 
client  at  all  reasonable  times,  if,  in  the  opinion  of  the  superintending  officers  of  such 
hospital,  asylum,  or  receptacle,  such  visit  would  not  be  injurious  to  such  person,  or  if 
a  judge  of  the  Supreme  Judicial  Court,  SuiDcrior  Court,  or  Probate  Court  in  any  county 
first  orders,  in  writing,  that  such  visits  be  allowed. 

Sec.  36. — Postal  Privileges  of  Patients. 

The  patients  in  the  lunatic  hospital,  asylum,  or  receptacle  for  the  insane  shall  be 
allowed  to  write  monthly  to  the  superintendent  or  to  the  State  board,  and  they  shall 
be  furnished  by  the  superintendent  with  all  materials  necessary  for  such  corresi^ond- 
ence  ;  and  a  letter-box  shall  be  placed  in  each  wai'd,  in  which  each  writer  may  deposit 
his  letters,  and  the  box  shall  be  opened  and  the  letters  distributed  monthly  by  the 
said  board. 

Acts  of  Massachusetts,  1883. 
Sec.  1. — Discharge  of  Inmates  from  Lunatic  Asylum  hy  Superintendent. 

The  Board  of  Trustees  of  the  State  lunatic  asylums,  or  of  the  Massachusetts  Gen- 
eral Hospital,  may  by  vote  confer  on  the  superintendent  of  the  hospital  or  asylum 
under  their  control  authority  to  discharge  therefrom  any  inmate  thereof  committed 
thereto  as  an  insane  person,  provided  due  written  notice  of  intention  so  to  discharge 
shall  be  sent  by  said  superintendent  to  the  person  or  persons  who  originally  sent  the 
petition  for  the  commitment  of  such  inmate. 

Sec.  2. — Temporary  Absence  from  the  Hospital  hy  the  Permission  of  the  Superintendent. 

Said  superintendent  may  also,  when  he  shall  deem  it  advisable,  permit  any  such 
inmate  to  leave  the  hospital  or  asylum  temporarily,  in  charge  of  his  guardian,  rela- 
tives, or  friends,  for  the  period  not  exceeding  sixty  days,  and  receive  him  when 
returned  by  such  guardian,  relatives,  or  friends  within  such  period  without  fm-ther 
order. 

Public  Acts  op  Michigan,  1885. 

Sec.  1. —  .  .  .  The  asylums  for  the  insane  of  the  State  of  Michigan  shall  be 
under  the  control  of  separate  boards  of  trustees. 

Sec.  5. — Appointment  of  the  SuperintendoU,  .  .  .  Steward,  and  Assistant  Medical 

Superintendent.  .  .  . 

The  Board  of  Trustees  shall  severally  appoint  a  medical  superintendent,  who 
shall  be  a  well-educated  physician,  experienced  in  the  treatment  of  the  insane,  and 
a  treasurer,  not  one  of  their  number,  who  shall  give  bonds  for  the  performance  of  his 
trust,  in  such  sum  and  with  sucli  sureties  as  the  director-general  of  the  State  shall 
approve.  They  shall  also  appoint,  \ii>on  the  nomination  of  the  medical  superintend- 
ent, a  steward  and  a  chaplain;  and  also,  in  a  like  manner,  an  assistant  medic;il 
superintendent  and  necessary  assistant  physicians.  All  medical  officers  shall  reside 
at  the  asylum.  ,  .  . 


652  AFPESDIX. 

Sec.  12. — Powers  and  Duties  of  the  Medical  Superintendent, 

The  medical  superiniendent  shall  be  the  chief  executive  officer  of  the  asyliim. 
He  shall  have  the  general  superintendence  of  the  buildings,  gi'ounds,  and  farm, 
together  with  the  furnitui'e,  fixtures,  and  stock ;  and  the  direction  and  control  of  all 
persons  therein,  subject  to  the  by-laws  and  regulations  established  by  the  trustees. 
He  shall  daily  ascertain  the  condition  of  all  j)atieuts,  and  prescribe  for  their  treatment 
in  the  manner  directed  in  the  by-laws.  He  shall  have  the  nomination  of  his  co-resi- 
dent officers,  with  power  to  assign  them  to  their  respective  duties,  subject  to  the 
by-laws ;  also  to  appoint,  with  the  apj^roval  of  the  trustees,  such  and  so  ma,ny  other 
assistants  and  attendants  as  he  may  think  necessary  and  proper  for  the  economical 
and  efficient  performance  of  the  business  of  the  asylum,  and  to  prescribe  their  several 
duties  and  places,  and  fix,  with  the  approval  of  the  trustees,  their  compensation,  and 
to  discharge  any  of  them  at  his  will  and  discretion ;  but  in  every  case  of  discharge  he 
shall  forthwith  record  the  same,  with  the  reasons  of  discharge,  under  a  proper  head 
in  one  of  the  books  of  the  asylum.  He  shall  also  have  the  power  to  suspend  until 
the  next  meeting  of  the  trustees,  for  good  and  sufficient  cause,  a  resident  officer ;  but 
in  such  case  he  shall  forthwith  give  written  notice  of  the  fact,  with  its  cause  and  cir- 
cumstances, to  one  of  the  trustees,  whose  duty  thereuj)on  shall  be  to  call  a  special 
meeting  of  the  board  to  provide  for  the  exigency.  He  shall  also,  fi-om  time  to  time, 
give  such  orders  and  instructions  as  he  may  judge  best  calculated  to  insure  good 
conduct,  fidelity,  and  econouiy  in  every  department  of  labor  and  expense ;  and  he  is 
authorized  and  enjoined  to  maintain  well-directed  discipline  among  all  who  are  em- 
ployed by  the  institution,  and  to  enforce  direct  compliance  with  such  instructions  and 
uniform  obedience  to  all  rules  and  regulations  of  the  asylum.  He  is  authorized  and 
directed  to  use  every  proper  means  to  fiu'nish  employment  to  such  patients  as  ma,v 
be  benefited  by  regular  labor  suited  to  their  capacity  and  strength.  He  shall  further 
cause  full  and  fair  accounts  and  records  of  all  his  doings  and  the  entire  business  and 
operations  of  the  institution  to  be  kept  regularly  from  day  to  day,  in  books  ijro^ided 
for  that  purpose,  in  the  manner  and  to  the  extent  prescribed  in  the  by-laws ;  and  he 
shall  see  that  all  such  accounts  are  fully  made  up  to  the  last  day  of  September  imme- 
diately preceding  the  meeting  of  the  legislature,  and  that  the  principal  facts  and 
results,  with  his  reports  thereon,  be  at  the  time  presented  to  the  trustees.  It  shall 
be  the  duty  of  the  medical  superintendent  to  admit  any  member  of  the  Board  of 
Trustees  in  every  part  of  the  asylmn,  and  to  exhibit  to  him  or  them  on  demand  all  the 
books,  papers,  and  accoimts  and  writings  belonging  to  the  institution  or  pertaining 
to  its  biisiness,  management,  discipline,  or  government ;  also  to  fiu'nish  coijies  of 
abstracts  and  reports  whenever  reqnii-ed  by  the  board.  The  medical  superintendent 
shall  make,  in  a  book  kept  for  that  purpose,  at  the  time  of  reception,  a  minute  with 
date  of  same,  the  name,  residence,  office,  and  occuxiation  of  the  person,  by  whom  and 
by  whose  authority  each  insane  person  is  bi'ought  to  the  asylum ;  and  shall  have  all 
the  orders,  warrants,  requests,  certificates,  and  other  papers  accompanying  him  forth- 
with filed.  The  assistant  medical  superintendent  shall  perform  the  duties  and  be  sub- 
ject to  the  responsibility  of  the  medical  superintendent  in  his  sickness  or  absence. 

Laws  of  1889. 

Sec.  21. — Certificate  of  Admission  of  Patients —  .  .  .  Duty  of  Medical  Superintendent 

to  Notify  Judge,  etc. 

No  person  shall  be  admitted  or  held  as  a  private  patient  in  any  asylum,  public  or 
private,  or  any  institution,  home,  or  retreat  for  the  care  or  treatment  of  insane,  except 
upon  the  certificate  of  two  reputable  physicians  imder  oath,  appointed  by  the  judge 
of  Probate  Court  where  such  alleged  insane  person  resides  to  conduct  an  examination, 
and  an  order  from  the  said  judge  of  tlie  Probate  Com-t  setting  forth  that  the  said  per- 
son is  insane,  and  directing  his  removal  to  an  asylum  or  institution  for  the  care  of  in- 
sane ;  no  person  shall  be  held  in  confinement  in  any  siich  asylum  or  institution  for 
more  than  fourteen  days  without  such  certificate  or  order. 

Sec.  22. — Qualifications  of  Physicians  Certifying  to  Insanity,  etc. 

It  shall  not  be  lawful  for  any  pliysician  to  certify  to  the  insanity  of  any  person  for 
the  purpose  of  securing  his  admission  to  an  asylum,  unless  such  physician  be  of  repu- 
table character  and  gi-aduate  of  some  incorporated  medical  college,  a  permanent  resi- 


APPENDIX.  Go'J 

<lent  of  tlie  State,  I'egistered  according  to  law,  not  related  by  blood  or  marriage  to  the 
alleged  insane  person  nor  to  the  person  applying  for  such  certificate,  and  shall  have 
been  in  actual  practice  of  his  profession  for  at  least  three  years ;  and  such  qualifica- 
tion shall  be  certified  to  by  tlie  clerk  of  the  county  in  which  sucli  physician  resides. 
No  certificate  of  insanity  shall  be  made  except  under  tlie  personal  examination  of  the 
party  alleged  to  be  insane  ;  and  it  shall  not  be  lawful  for  any  ])hysician  to  certify  to 
the  insanity  of  any  person  for  the  purpose  of  committing  him  to  an  asylum  for  which 
the  said  physician  is  eitliei-  a  trustee  or  a  superintendent,  proprietor,  an  officer,  or  a 
regular  professional  attendant.   .   .   . 

Sec.  37. —  .   .   .  llciwrthij  the  Mc<ikal  Si(perintcn<ie)d  of  tlie  IiisuiUi  Asylnm.  .  .   . 

.  .  .  The  medical  superintendents  of  the  several  insane  asylums  sliall  report 
quarterly  to  the  secretary  of  the  Board  of  Corrections  and  Charities  the  names  and 
ages  of  all  jiatients  supported  at  State  or  county  charge ;  .  .  .  :ind  shall  also  report 
to  the  secretary  of  the  Board  of  (Corrections  and  Charities  the  date  and  circumstances 
attending  the  discharge,  removal,  elopement,  or  death  of  all  insane  persons  received, 
aided,  or  supported  at  county  or  State  charge.  .   .  . 

Sec.  38. —  .   .   .  Preference  m  Admission,  etc.,  when  Lack  of  Room  for  All. 

...  In  ease  the  sujierinteudents  of  the  asylums  find  it  imijossible  to  receive  all 
patients  for  whom  application  is  made,  they  may,  at  tlieir  discretion,  give  preference 
to  those  for  whom,  in  their  judgment,  treatment  is  most  urgently  necessary.  To  make 
room  for  urgent  cases  they  are  also  authorized  to  order  the  removal  from  the  asylum 
to  his  home  and  friends,  or  to  the  superintendent  of  the  poor  of  the  comity  whence  he 
came,  of  any  patient  that  in  their  judgment  may  safely  reside  outside  of  the  institu- 
tion. 

Sec.  47. — Definition  of  Terms  "Tiimne"  and  "Insane  Persons." 

The  terms  "insane"  or  "insane  persons,"  as  used  in  this  act,  include  every  spe- 
-cies  of  insanity  and  extend  to  every  derangement  of  persons  and  to  all  of  unsound, 
mind  other  than  idiots.  .   .  . 


General  Acts,  Minnesota,  1887. 

Chapter  146,  Section  1. — Postal  Eighis  of  Insane  Persons. 

That  henceforth  each  and  every  inmate  of  each  and  every  insane  asylum,  both 
public  and  private,  in  the  State  of  Minnesota,  shall  be  allowed  to  choose  one  indi- 
vidual from  the  outside  world  to  whom  he  or  she  may  write  when  and  whatever  he  or 
she  may  desire,  and  over  these  letters  to  the  individual  there  shall  be  no  censorship 
exercised  or  allowed  by  any  of  the  asylum  officials  or  employees,  but  their  postal 
rights,  so  far  as  this  one  individual  is  concerned,  shall  be  as  free  and  unrestricted  as 
are  those  of  any  resident  or  citizen  of  the  State  of  Minnesota,  and  shall  be  imder  the 
protection  of  the  same  postal  laws  ;  and  each  and  every  inmate  shall  have  the  right  to 
make  a  new  choice  of  his  individual  partly  every  three  months  if  he  or  she  so  desires 
to  do  ;  and  all  such  letters  shall  be  dropped  by  the  waiter  thereof,  accompanied  by  an 
attendant  when  necessaiy,  into  a  post-office  box  provided  by  the  State  at  the  insane 
asylum  and  kept  in  some  jilace  easy  of  access  to  all  the  patients ;  tlie  attendant  is 
required,  when  necessary,  to  see  that  this  letter  is  directed  to  the  patient's  corre- 
spondent, and  if  it  is  not  so  directed  it  must  be  held  subject  to  the  superintendent's 
disposal ;  and  the  contents  of  the  box  shall  be  collected  once  every  week  by  the  author- 
ized person  from  the  Post-office  Department,  and  by  him  placed  into  the  hands  of  the 
United  States  mail  for  delivery. 

Sec.  2. — Duties  of  the  Superintendent  of  the  Insane  Asijhnn. 

That  it  is  hereby  made  the  duty  of  the  superintendent  to  keep  registered  and 
posted  in  some  piiblic  place  at  the  insane  asylum  a  copy  of  the  names  of  every  indi- 
vidual chosen  as  an  inmate's  correspondent,  and  by  whom  chosen;  and  it  is  hereby 
made  the  duty  of  the  superintendent  to  inform  eacli  of  the  individuals  named  of  the 
party  choosing  him  or  her,  and  he  is  to  request  him  or  her  to  write  hi^s  or  her  ovrn. 
name  on  the  outside  of  the  envelope  of  every  l(>tter  lie  or  she  wi'ites  to  this  individual 
inmate;  and  all  these  letters  bearing  the  iiulividiial  writer's  name  on  the  outside  he 
is  requested  to  deliver,  or  cause  to  be  delivered,  any  letter  or  writing  to  him  or  her 


65-4  APPENDIX. 

directed,  without  opening  or  reading  the  same,  or  allowing  it  to  be  opened  or  read, 
iinless  there  is  reason  for  believing  the  letter  contains  some  foreign  substance  which 
may  be  used  for  medication,  in  which  case  the  letter  shall  be  required  to  be  opened 
in  the  presence  of  a  competent  witness,  and  this  substance  shall  be  delivered  to  the 
superintendent,  to  be  used  at  his  discretion. 

Sec.  4. — Superintendent  to  Provide  Registers  and  Stationery. 

It  shall  be  the  duty  of  the  superintendent  of  each  hospital  or  asylum  for  insane  to 
furnish  each  assistant  physician  with  a  pocket-register  of  correspondence,  in  such  way 
as  the  State  Department  of  Corrections  and  Charities  may  prescribe,  and  to  keep  on  hand 
some  envelopes,  j)aper,  and  postal  cards,  which  shall  be  used  for  each  correspondent. 
Such  registers  and  stationery  shall  be  furnished  on  requisition  of  the  assistant  physi- 
cians, and  shall  be  paid  for  from  the  current  expense  funds  of  such  institution.  .   .   . 

Whenever  any  letter  or  postal  card  from  any  correspondent  chosen  under  this  act 
shall  be  delivered  to  any  assistant  physician  by  the  superintendent,  he  shall  delivei- 
the  same  to  the  inmate  to  whom  it  is  addressed,  without  unnecessary  delay,  taking 
the  receipt  of  said  inmate  therefor. 

Sec.  6. — Tlie  Superintendent  to  Mail  and  Deliver  Letters. 

...  It  shall  be  the  duty  of  the  superintendent,  upon  receipt  of  such  letters  from 
the  assistant  physician,  if  he  shall  find  that  the  said  letter  is  addressed  to  a  corre- 
spondent duly  chosen  imder  this  act,  to  place  such  letter,  or  cause  it  to  be  placed,  in 
the  United  States  mail  without  opening  or  reading  the  same.  It  shall  be  the  duty  of 
the  superintendent  to  request  the  said  correspondents  to  write  their  names  on  the 
outside  of  the  letters  sent  by  them  to  the  inmates.  The  said  superintendent  shall 
deliver  such  letters  to  the  assistant  physician,  to  be  given  to  the  inmates  to  whom  they 
are  addressed,  unless  in  the  judgment  of  the  said  superintendent  the  receipt  of  such 
letters  would  be  injurious  to  such  inmates,  in  which  ease  they  shall  forthwith  notify 
such  correspondents  that  such  letters  are  withheld,  stating  the  reasons  therefor,  and 
recording  the  fact  in  the  register  of  correspondence.  No  letter  wi-itten  by  a  corre- 
siDondent  to  an  inmate  shall  be  opened  by  any  superintendent,  unless  he  has  reason  to 
suspect  that  it  contains  such  matter  as  ought  not  to  be  delivered  to  said  inmate,  in 
which  case  he  shall  record  the  fact  that  such  letter  has  been  opened,  and  the  reasons 
therefor,  in  the  register  of  correspondence. 

Sec.  7. — Inmates  may  Correspond  iciih  the  Governor  and  the  Secretary  of  the  State  Board 

of  Corrections  and  Charity. 

.  .  .  Each  and  every  inmate  of  any  hosisital  for  the  insane  in  the  State  shall  have 
the  priAdlege  of  communicating  in  Avriting  with  the  governor  and  the  secretary  of  th& 
State  Board  of  Corrections  and  Charities,  in  the  same  manner,  under  the  same  regu- 
lations, as  with  the  correspondents  chosen  under  this  act. 

Chapter  14,  Section  267. — Physician  to  Examine  Alleged  Insane  Person. 

Upon  the  filing  of  information  the  court  shall  make  an  order  directed  to  two  (2) 
persons,  one  of  whom  at  least  shall  be  a  duly  qualified  physician  ;  and  such  persons,  in 
connection  with  the  judge  of  probate,  shall  constitute  a  jury  to  examine  the  person 
alleged  to  be  insane,  and  they  shall  ascertain  the  fact  of  sanity  or  insanity. 

Sec.  274. —  When  Discharged,  Probate  Court  to  be  Notified. 

When  any  person  who  has  been  committed  to  the  care  and  custody  of  the  superin- 
tendent of  the  hospital  by  warrant  of  the  Probate  Court  shall  be  discharged  from  such 
hospital,  the  superintendent  shall,  upon  day  of  such  discharge,  send  by  mail  to  the 
judge  of  probate  of  the  coimty  i7i  which  siich  warrant  was  issued  a  certificate  signed 
by  him,  stating  that  the  person  has  been  discliarged  from  such  hospital,  and  the  date 
of  such  discharge,  which  certificate  shall  be  filed  in  the  Probate.  Court. 

Code  op  Mississippi,  1880. 

Sec.  665. — The  medical  superintendent  shall  have  power  to  appoint  and  re- 
move all  subordinate  oificcrs  and  employees  allowed  by  the  trustees,  and  he  shall 
make,  in  a  book  kept  for  that  purpose,  at  the  time  of  reception,  a  minute  with  the 


.irrKXDix.  G35 

date  of  reception,  with  name,  a{?e,  sex,  residence,  office  or  occupation  of  the  person, 
and  by  whom  and  by  whose  autliority  each  insane  person  is  broujjlit  to  the  asylum, 
and  have  all  orders,  warrants,  requisitions,  certificates,  and  otlier  papers  accompany- 
ing him  or  her  carefully  liled,  and  liave  them  copied  in  said  book.  .  .  .  He  shall 
ascertain  the  condition  of  the  patients,  and  i)rescribe  their  treatment  in  the  manner 
prescribed  in  the  said  by-laws;  and  he  shall  also  be  required  to  see  that  all  the  rules 
and  regulations  for  the  tliscipline  and  good  govei-nment  of  the  institution  are  i^roperly 
obeyed  and  enforced. 

Skc  6.59. — Any  person  being  a  lunatic  and  resident  of  the  State  of  Mississippi 
shall  be  admitted  into  the  asylum  free  of  charge.   ... 

Skc.  660. — It  shall  be  the  duty  of  the  superintendent  to  admit  into  the  asylum  all 
persons  ordered  to  be  placed  therein  after  an  inquest  of  lunacy,  in  the  due  order  of 
registration,  if  there  be  a  vacancy  in  such  asylum,  on  the  presentation  of  a  dvdy  certi- 
iied  copy  of  such  order  under  the  seal  of  Chancery  Coiu-t,  showing  thereby  admission 
of  the  patient  to  the  asylinu. 

Sec.  661. — On  application  in  behalf  of  any  person  being  a  lunatic  and  a  resident 
of  this  State,  for  liis  or  her  admission  into  the  asylum,  the  superintendent  and 
Board  of  Trustees  may,  if  they  think  he  or  she  ought  to  be  admitted,  receive  him  or 
her  as  a  patient  therein,  even  though  no  proceedings  in  lunacy  have  been  instituted 
as  hereinafter  provided  for. 

Sec.  663. — In  case  the  friends  or  relations  of  any  lunatic  shall  neglect  or  refuse  to 
place  him  or  her  in  said  asylum,  and  shall  permit  him  or  her  to  go  at  large,  it  shall  be 
the  duty  of  the  clerk  of  the  Chancery  Court  of  any  county  in  which  such  lunatic  may 
reside  or  be  found  going  at  large,  on  the  suggestion,  in  writing,  of  any  citizen  of  the 
county,  to  direct  the  sheriff,  by  writ  of  lunacy,  to  summon  as  soon  as  may  be  the 
alleged  lunatic  and  six  discreet  persons  of  the  comity  in  which  such  lunatic  is  going 
at  large,  to  make  inquisition  thereto  on  oath,  and  the  result  of  such  inquisition  to  be 
returned  to  the  said  court  forthwith ;  and  if  the  person  said  to  be  a  lunatic  shall  be 
adjudged  by  such  inquest,  or  a  majoi'ity  of  them,  to  be  insane,  and  one  who  should  be 
confined  therein,  the  said  clerk  shall  order  said  sheriif  to  arrest  said  lunatic,  and  place 
him  or  her  in  said  asylum  if  there  be  a  vacancy,  or,  if  there  be  no  vacancy,  to  confine 
such  lunatic  in  the  county  jail  until  room  can  be  had  in  the  liuiatic  asylum.  .  .  . 


Revised  Statutes  of  Missouri,  1889. 
Sec.  471. — Superintendent's  Duties. 

The  superintendent  shall  be  a  physician  of  knowledge,  skill,  and  ability  in  his 
profession,  and  have  experience  in  the  management  and  treatment  of  insane ;  he 
shall  not,  while  such  superintendent,  engage  in  the  practice  of  his  profession,  but 
shall,  to  the  exclusion  of  all  other  business,  devote  himself  to  the  super\'ision  and 
care  of  the  asylum  and  its  inmates.  Before  entering  on  the  diities  of  his  office  he 
shall  take  an  oath  or  affirmation  that  he  will  diligently,  faithfuUj-,  and  impartially 
discharge  all  the  duties  required  of  him  by  the  law. 

Sec.  473. — Patients — How  Admitted  and  Discharged. 

Persons  afflicted  with  any  form  of  insanity  may  be  admitted  into  the  asylum  when 
the  superintendent  deems  it  probable  that  their  conelition  can  be  improved  by  the 
care  and  treatment  of  the  institution ;  and  any  person  may  be  dischai'ged  by  the 
superintendent  whenever  he  may  believe  that  the  condition  of  such  person  cannot  be 
improved  by  a  longer  stay  in  the  asylum. 

Sec.  478. — Pan-puticnts — How  Admitted. 

Pay-patients,  or  those  not  sent  to  the  asylum  by  order  of  the  eom-t,  may  be  ad- 
mitted on  such  terms  as  shall  be  by  this  chapter,  and  the  by-laws  of  the  asylum,  pre- 
scribed and  regulated. 

Sec.  479. — Terms  of  Admission. 

Preparatory  to  the  admission  of  such  a  patient  the  superintendent  shall  be  fur- 
nished with  a  request.  .  .  .  stating  Ids  age  and  place  of  nativity,  if  knowni,  his  Cliris- 
tian  and  surname,  place  of  residence,  occupation,  and  degree  of  relationship,  or  any 


€56  AFPEXniX. 

<;ireiimstances  of  connection  between  Mm  and  the  person  requesting  Ms  admission ; 
and  a  certificate  .  .  .  dated  AvitMn  two  months,  nnder  oath,  signed  br  two  physicians, 
of  the  fact  of  his  being  insane.  Such  person  signing  such  request  or  certificate  shall 
annex  to  Ms  name  his  profession  or  occupation,  and  the  township,  county,  and  State 
of  residence,  tmless  these  appear  on  the  face  of  the  document.  Before  any  probate 
patient  shall  be  received  into  the  asylum  there  shall  be  produced  to  the  superintendent 
a  receipt  from  the  treasurer  of  the  asylum,  acknowledging  the  payment  to  him  of  at 
least  thirty  days'  charge  in  advance,  and  sufficient  bond  to  the  said  treasurer  condi- 
tioned with  the  obligees  to  secui'e  the  payment  of  the  charges  incun-ed  in  behalf,  on 
account,  of  said  patient.   .  .   . 

No  board  constituting  thirty  days'  payment  shall  be  refimded  if  a  patient  making 
such  payment  shall  be  taken  away  within  the  period,  uneured  and  against  the  consent 
of  the  superintendent. 

Chapter  86,  Section  5513. — On  Information — Probate  Court  to  Inquire  as  to  Sanity. 

If  any  information  in  waiting  be  given  to  the  Probate  Court  that  any  person  in  its 
county  is  an  idiot,  lunatic,  or  person  of  unsound  mind,  and  incapable  of  mahaging  Ms 
affairs,  and  pray  that  an  inquiry  thereinto  be  had,  the  coui-t,  if  satisfied  that  there  is 
good  cause  for  the  exercise  of  its  jurisdiction,  shall  cause  the  facts  to  be  inquired  into 
by  a  jmy. 

Sec.  5550. — To  he  Discharged — JVIten. 

If  it  be  found  that  such  person  has  been  restored  to  his  right  mind,  he  shaU  be 
discharged  from  the  care  and  custody,  and  the  guardian  shall  immediately  settle  Ms 
accounts  and  restore  to  his  person  the  things  remaimng  in  his  hands  belonging  or 
pertaining  to  him ;  and  if  it  be  found  that  such  person  has  not  been  restored  to  his 
right  mind,  the  person  at  whose  instance  the  inquiry  was  had  may,  in  the  discretion 
of  the  coui't,  be  required  to  pay  the  cost  of  proceeding. 


Statutes  of  Montana,  1887. 
Sec.  1215. — Examination  of  Person  Alleged  to  he  Insane. 

From  and  after  the  passage  of  this  article  it  shall  be  the  duty  of  the  probate 
judge,  or,  in  Ms  absence  or  incapability  to  act,  the  chairman  of  the  Board  of  Cormty 
Commissioners  of  the  several  coimties  of  this  Territory,  upon  the  application  of  any 
person  under  oath,  setting  forth  that  any  person  by  reason  of  insanity  is  unsafe  to  be 
at  large  or  is  suffering  imder  mental  derangement,  to  cause  said  person  to  be  brought 
before  him,  at  such  time  and  place  as  he  may  direct ;  and  the  said  judge  or  commis- 
sioner shall  also  cause  to  appear,  at  the  same  time  and  place,  a  jui-y  of  three  persons 
of  his  county,  one  of  whom  shall  be  a  licensed  practieijig  jjliysician,  who  shall  proceed 
to  examine  the  person  alleged  to  be  insane  ;  and  if  such  jury  after  careful  examination 
shall  certify  upon  oath  that  the  charged  is  a  lunatic,  and  the  said  judge  or  commis- 
sioner is  satisfied  that  siicli  person  by  reason  of  insanity  is  unsafe  to  be  at  large,  or  is 
incompetent  to  pro'S'ide  for  his  or  her  own  proper  care  and  sujiport,  and  has  no  prop- 
erty available  for  that  purpose,  and  has  no  kindred  in  the  degree  of  husband  or  wife, 
father  or  mother,  children,  or  brother  or  sister,  li^-ing  within  the  Territory,  of  suffi- 
cient means  and  ability-  to  pro^^ide  for  such  care  and  maintenance,  or  if  he  or  she 
have  kindred  within  the  Territory  and  such  kindred  fail  or  refiise  to  properly  care 
for  and  maintain  such  insane  person,  such  judge  or  county  commissioner  shall  make 
out  a  duplicate  warrant  reciting  such  facts,  and  place  it  in  the  hands  of  the  sheriff 
of  said  coimty,  who  shall  immediately,  in  compliance  therewith,  have  the  person  or 
persons  therein  named  apprehended,  and  deliver  him  or  her  or  them  to  the  director 
aforesaid,  at  the  place  designated  in  the  notification.  .  .   . 

Sec.  1227. — Inmates  mai/  he  Discharged  upon  Beport  of  Physician. 

The  governor  shall  direct  and  have  discharged  fi'om  the  insane  asylum  any  of  the 
inmates  thereof  at  any  time  when,  from  the  wi'itten  report  to  him  by  the  physicians  in 
charge  of  said  asylum,  or  either  of  them,  or  fi-om  any  lahysician  who  shall  be  appointed 
to  Aisit  and  examine  said  institution,  he  believes  such  discharge  should  be  granted; 
provided  that  the  report  upon  which  he  may  act  shall  be  filed  and  kept  in  his  hands. 


APPENDIX.  657 


Sec.  1230. — Inmates  of  an  Jsijlum  may  Choose  Confidential  Correspondent. 

.  .  .  Each  and  every  inmate  of  each  and  eveiy  asyhim,  both  public  and  private, 
shall  be  allowed  to  choose  one  individual  from  the  outside  world,  to  whom  he  or  she 
may  write  when  and  whatever  he  or  siie  desires,  and  over  these  letters  to  this  indi- 
vidual there  shall  bo  no  censorship  exercised  or  allowed  by  any  ojie  of  the  asylum 
officials  or  employees,  but  their  post-office  rights  so  far  as  this  one  individual  is  con- 
cerned sliall  be  as  free  and  unrestricted  as  those  of  any  other  resident  or  citizen  of  tlie 
Territory  of  Montana,  and  sliall  be  under  the  protection  of  the  same  postal  laws ;  and 
each  and  every  inmate  sliall  have  tJie  right  to  make  a  new  choice  of  this  individunl 
party  every  three  months  if  he  or  she  desires  to  do  so.  And  it  is  here  made  the  duly 
of  the  superintendent  to  furnish  each  and  every  inmate  of  every  insane  asylum 
in  this  Territory,  either  public  or  private,  with  suitable  material  for  writing,  inclos- 
ing, sealing,  stamping,  and  mailing  letters,  sufficient  at  least  for  the  writing  of  one 
letter  a  week,  provided  they  request  the  same,  unless  they  are  otherwise  furnished 
with  such  materials ;  and  all  such  letters  shall  be  dropped  by  the  writers  thereof, 
accompanied  by  an  attendant,  into  the  post-office  box  i^rovided  by  the  deimrtment  at 
the  insane  asylum  and  kept  in  some  place  easy  of  access  to  all  the  patients ;  the 
attendant  is  required  in  all  cases  to  see  that  this  letter  is  directed  to  the  patient's 
correspondent,  and  if  it  is  not  so  directed  it  must  be  held  subject  to  the  superin- 
tendent's disposal ;  and  the  contents  of  this  box  shall  be  collected  once  every  week  by 
an  authorized  jserson  from  the  Post-office  Department,  and  by  him  placed  in  the  hands 
of  the  United  States  mail  for  delivery. 

Sec.  1231. — Lists  of  Correspondents  to  he  Eegistered  and  Posted. 

That  it  is  hereby  made  the  duty  of  the  superinj;endent  to  keep  registered  and 
posted  in  some  public  place  at  the  insane  asylum  a'  true  copy  of  the  name  of  every 
individual  chosen  as  an  inmate's  correspondent,  and  by  whom  chosen ;  and  it  is 
hereby  made  the  duty  of  the  superintendent  to  inform  each  of  the  individuals  of  the 
name  of  the  party  choosing  him  or  her,  and  to  request  him  or  her  to  wi"ite  his  or  her 
name  on  the  outside  of  the  envelope  of  every  letter  he  or  she  writes  to  this  individual 
inmate ;  and  all  these  letters  bearing  individual  writers'  names  on  the  outside  he  is 
requested  to  deliver,  or  cause  to  be  delivered,  any  letter  or  writing  to  him  or  her 
directed,  without  opening  or  reading  the  same,  or  allowing  it  to  be  opened  or  read, 
unless  there  is  reason  for  suspecting  that  the  letter  contains  some  foreign  substance 
which  might  be  used  for  medication,  in  which  case  the  letter  shall  be  required  to  be 
opened  in  the  presence  of  competent  witnesses,  and  this  substance  shall  be  delivered 
to  the  superintendent,  to  be  used  at  his  discretion. 


Nebraska  Compiled  Statutes,  1887. 
Sec.  2. — Post-office  Privileges  of  Inmates. 

.  ,  .  Henceforth  there  shall  be  no  censorship  exercised  over  the  correspondence 
of  the  inmates  of  the  hospital  for  the  insane  in  this  State,  but  their  post-office  rights 
shall  be  as  free  and  unrestricted  as  are  those  of  any  resident  or  citizen  of  this  State, 
and  be  under  the  protection  of  the  same  postal  laws,  and  every  inmate  shall  be  allowed 
to  write  when  and  whatever  he  or  she  desires  to  any  person  he  or  she  may  choose. 
And  it  is  hereby  made  the  duty  of  the  superintendent  to  furnish  each  and  every  in- 
mate of  each  and  every  insane  asylum  in  this  State  with  suitable  material,  at  the 
expense  of  the  State,  for  writing,  inclosing,  sealing,  stamping,  and  mailing  letters, 
sufficient  for  Writing  at  least  one  letter  a  week,  provided  they  request  the  same,  unless 
they  are  otherwise  furnished  with  such  material.  .  .  . 

Sec.  11. — Duties  and  Poirer  of  the  Siq^erintendent. 

The  superintendent  of  said  institution  shall  be  a  physician  of  acknowledged  skill 
and  ability  in  his  profession,  and  be  a  graduate  of  a  regular  medical  college.  He  shall 
be  the  chief  executive  officer  of  the  hospital,  and  shall  hold  his  office  for  the  term  of 
six  years,  unless  sooner  removed  by  the  governor,  for  malfeasance  in  office,  or 
other  good  and  sufficient  cause.     He  or  the  assistant  physician  must  be  in  daily 


658  AFPEXDIX. 

.attendanee  at  tlie  hospital,  and  in  no  instance  must  they  both  be  absent  at  the  same 
time.  Before  entering  upon  the  duties  of  his  office  he  shall  take  and  prescribe  an 
•oath  for  the  faithful  and  diligent  discharge  of  the  duties  required  by  law.  He  shall 
have  the  entii'e  control  of  the  medical,  moral,  and  dietetic  treatment  of  patients,  and 
shall  see  that  the  several  officers  of  the  institution  faithfully  and  diligently  discharge 
their  respective  duties.  He  shall  employ  attendants,  servants,  nurses,  and  such  per- 
sons as  he  may  deem  necessary  for  the  efficient  and  economical  administration  and 
government  of  the  asylum. 

Sec.  21. — Ai^plication  for  Admission  to  tJie  Hospital. 

Application  for  admission  to  the  hospital  must  be  made  in  vn-iting  in  the  natm'e 
of  information  validiiied  by  af&davit ;  such  information  must  allege  that  the  person  in 
whose  behalf  the  application  is  made  is  believed  hj  the  informant  to  be  insane  and  a 
fit  subject  for  custody  and  treatment  in  the  hospital ;  that  such  person  is  found  in  the 
county  and  has  an  alleged  settlement  therein,  if  such  is  known  to  be  the  fact ;  and,  if 
such  settlement  is  not  in  the  county,  where  it  is,  if  known,  or  where  it  is  believed  to 
be,  if  the  informant  is  advised  on  the  subject. 

Sec.  12. — Investigation  of  tlie  Commissioners. 

On  the  filing  of  any  information  as  above  provided,  the  commissioners  shall  at 
once  take  steps  to  investigate  the  grounds  of  the  information.  For  this  purpose  they 
may  reqmre  that  the  person  for  whom  such  admission  is  sought  be  brought  before 
them,  and  that  the  examination  be  had  in  his  or  her  presence.  .  .  .  The  commission- 
ers, whether  they  decide  to  dispense  with  the  presence  of  such  person  or  not,  shall 
appoint  some  legally  practicing  physician  of  the  county  to  visit  or  see  such  person, 
and  make  a  personal  examination  touching  the  truthfulness  of  the  allegation  in  the 
information,  and  adjudge  the  actual  condition  of  such  person,  and  forthwith  report  to 
them  thereon  j  and  said  physician  may  or  may  not  be  of  their  own  number;  and  the 
physician  so  appointed  and  acting  shall  certify  in  his  own  hand  that  he  has,  in  pui'- 
suance  of  his  appointment,  made  a  careful  personal  examination  as  required ;  and 
that  on  such  examination  he  finds  the  person  in  question  insane,  if  such  is  the  fact ; 
and,  if  otherwise,  not  insane ;  and  in  connection  with  his  examination  the  said 
physician  shall  endeavor  to  obtain  from  the  relatives  of  the  person  in  question,  or 
from  others  who  know  the  facts,  correct  answers  so  far  as  made  in  the  interrogatories 
hereinafter  required  to  be  propounded  in  such  cases,  which  interrogations  and  answers 
shall  be  attached  to  the  certificate. 


Statutes  op  Nevada,  1889. 

Chapter  39,  Section  1. — Whenever  by  reason  of  absence  of  the  district  judge  of 
the  coTinty  an  insane  i^erson  cannot  be  brought  before  him  for  examination,  he  may 
be  taken  before  the  county  clerk  of  such  county,  and  thereupon  said  county  clerk  shall 
be  vested  with  the  power  to  hold  such  examination  and  discharge  such  jDerson  or 
commit  him  to  the  insane  asylum  in  the  same  manner  as  may  be  done  by  the  district 
judge. 

General  Statutes,  1885. 
Sec.  1457. — District  Judge  to  Examine  Insane  Person — Physician  to  Attend. 

The  district  judge  of  any  judicial  district  in  this  State  shall,  tipon  application 
under  oath,  setting  forth  that  a  person  by  reason  of  insanity  is  dangerous  to  be  at 
large,  cause  any  person  to  be  brought  before  him,  and  he  shall  summon  to  appear, 
at  tlie  same  time  and  place,  two  or  more  witnesses  having  had  frequent  intercourse 
with  the  accused  dm-ing  the  time  of  alleged  insanity,  who  shall  certify  under  oath  as 
to  conversation,  manners,  and  general  conduct  upon  which  said  charge  of  insanity  is 
based  ;  and  he  shall  also  cause  to  appear  before  him  at  tlie  same  time  and  place  two 
gi'aduates  in  medicine,  before  whom  the  district  judge  shall  summon  a  jury,  and  if 
after  careful  hearing  of  the  case  and  a  personal  examination  of  the  alleged  insan.-' 
person  the  said  phy.sieians  shall  certify  on  oath  that  the  case  is  of  recent  or  curable 
character,  or  that  the  said  insane  person  is  of  a  homicidal,  suicidal,  or  incendiary 


A  I' P EX D IX.  G59 

■ilisiiosition,  or  if  from  any  otlier  violont  syinptojiis  tlic  said  insane  person  would  be 
dangerous  to  liis  or  lier  own  life,  or  to  the  lives  and  property  of  tlie  eonnnuiiity  in 
wliicii  he  or  she  may  live;  and  if  said  pliysieians  shall  also  certify  to  the  name,  age, 
nativity,  residence,  occupation,  length  of  time  in  tliis  State,  apparent  cause  and  class 
of  insanity,  duration  of  disease,  and  present  condition  as  nearly  as  can  be  ascertained 
by  inquiry  and  examination  ;  and  if  tlie  district  judge  slialL  be  satisfied  that  tlie  facts 
in  tlie  examination  establish  tlie  existence  of  insanity  in  tlie  person  of  the  accused, 
of  a  recent  or  curable  nature,  or  of  a  homicidal,  suiciihil,  or  incendiary  eliaracter,  or 
from  tlie  violent  symptoms  the  said  insane  person  would  be  dangerous  to  his  or  her 
own  life,  or  to  tlie  lives  and  property  of  others,  to  be  at  large,  he  sliall  direct  the 
sheriff  or  some  suitable  person  to  convey  to  the  eapitol  of  the  State  and  place  such 
insane  person  in  eliarge  of  tlie  secretary  of  tlie  State,  and  shall  transmit  duplicate 
copies  of  complaint  and  commitment  and  pliysicians'  certificates,  which  shall  also  be 
in  form  as  furnished  to  the  judge,  to  the  secretary  of  the  State. 


New  Hampshire  Laws,  1889. 

■Chapter  18,  Section  6. — Onli/  Fanper  Insane  in  Countij  Amjlunts — Beports  of  County 

Superintendent. 

No  person  otlier  than  a  pauper  shall  be  admitted  into  any  county  asylum,  and  the 
superintendent  of  every  asylum  or  other  place  in  this  State  where  insane  persons  are 
confined  shall,  within  three  days  after  the  commitment  of  any  person,  notify  the  board 
of  such  confinement  upon  a  blank  furnished  for  that  pm-pose ;  and  the  said  superin- 
tendent shall  at  all  times  furnish  such  information,  regarding  the  insane  in  Ms  charge 
as  the  State  board  may  request. 

1878. — Chapter  10,  Section  12. — Persons  Dangerous  to  he  Committed  to  the  Asylum. 

If  any  person  is  in  such  condition  as  to  render  it  dangerous  that  lie  should  be  at 
large,  the  judge  of  probate,  upon  petition  of  any  person  and  such  notice  to  the  select- 
men of  the  town  in  which  such  insane  person  is,  or  to  his  guardian,  or  to  any  other 
person  as  he  may  order — which  petition  may  be  filed,  notice  issued,  and  a  hearing  had 
in  vacation  or  otherwise — may  commit  such  insane  person  to  the  asylum. 

Sec.  18. — Certificate  of  tiro  Pliysicians  Pequired  to  Commit. 

No  person  shall  be  committed  to  the  asylum  for  the  insane,  except  by  order  of 
■court  or  the  judge  of  probate,  without  a  certificate  of  two  respectable  physicians  that 
such  person  is  insane,  given  after  a  personal  examination  made  within  one  week  of 
committal ;  and  such  certificate  shall  be  accompanied  by  a  certificate  of  the  judge  of 
the  Supreme  Court,  or  of  the  court  of  probate,  or  mayor  or  chairman  or  selectman,  testi- 
fying to  the  truthfulness  of  the  signatures  of  the  signers. 

Sec.  25. — Superintendent  may  Furnish  Stationery,  Paper,  and  Transmit  Letters  to 

Trustees. 

It  shall  be  the  duty  of  the  superintendent  to  furnish  stationery  to  any  patient  who 
may  desire  it,  and  transmit  any  letter  such  patient  may  address  to  the  Board  of  Trus- 
tees to  such  member  as  said  board  shall  have  designated  to  receive  such  correspond- 
ence, and  all  such  letters  shall  be  promptly  transmitted  without  interception. 

Laws  op  New  Jersey,  1889. 

Chapter  168. — Superintendent  or  Warden  to  Send  a  List  of  Patients  Chargeable  to  the 

County. 

...  It  shall  be  the  duty  of  the  superintendent  or  warden  of  the  respective  State 
asylums  for  the  insane  in  this  State,  at  which  patients  are  supported  at  the  expense 
of  any  county  of  this  State,  to  make  out  under  oath  and  send  to  the  clerk  of  the  Board 
of  Chosen  Freeliolders  of  each  and  every  county  supporting  patients  at  said  asylums, 
at  least  three  days  before  the  meeting  of  the  said  Board  of  Freeholders,  at  which  a 
quarterly  bill  of  said  asylum  shall  be  presented,  a  regular  and  quarterly  statement 
giving  the  names  of  all  patients  at  said  asylum  at  the  expense  of  the  coimty  for  whicli 


5G0  APFEXDIX. 

said  statement  is  made,  wlio  have  been  at  said  asylum  during  the  last  preceding  quar- 
ter, which  statement  shall  also  contain  the  dates  of  admission  of  the  respective 
patients,  the  township  from  which  they  came,  the  days  of  discharge  of  any  who  have 
been  discharged,  the  date  of  death  of  any  who  have  died,  and  the  dates  between  which 
they  have  been  away  on  a  visit  or  otherwise  during  the  quarter. 

Tkenton  Asylum,  1886. 

Sec.  1. — Admission  of  Patients. 

.  .  .  No  person  shall  be  admitted  into  the  asylum  as  a  patient  except  upon  the 
order  of  some  court  or  judge  aiithorized  to  send  patients,  without  lodging  with  the 
superintendent — first,  a  request  under  the  hand  of  the  person  by  whose  direction  he 
is  sent,  stating  his  age  and  place  of  nativity,  if  known,  his  Christian  and  surname, 
place  of  residence,  occupation,  and  degree  of  relationship,  and  other  circumstances  of 
connection  between  him  and  the  person  requesting  his  admission ;  and  second,  a 
certificate  dated  within  a  month,  under  oath,  signed  by  two  respectable  physicians, 
of  the  fact  of  his  being  insane.  Each  person  signing  svich  request  or  certificate  shall 
annex  to  his  name  his  profession  or  occupation,  and  the  townshij)  and  county  and 
State  of  his  residence,  unless  these  facts  appear  on  the  face  of  the  documents. 

Sec.  7. — Duties  and  Powers  of  Physician. 

The  superintendent  shall  be  the  chief  executive  oflicer  of  the  asylum.  He  shall 
have  the  general  superintendence  of  all  the  buildings,  grounds,  and  farm,  with  their 
furnitiire,  fixtures,  stock,  and  the  direction  and  control  of  all  persons  therein,  subject 
to  the  laws  and  regulations  established  by  the  managers.  He  shall  daily  ascertain  the 
condition  of  the  patients,  and  prescribe  their  treatment  in  the  manner  prescribed  in 
the  by-laws.  He  shall  appoint,  with  the  approval  of  the  managers,  so  many  assistants 
and  attendants  as  he  may  think  proper  and  necessary  for  the  economical  and  efficient 
performance  of  the  business  of  the  asylum,  and  prescribe  their  several  duties  and 
places,  and  fix,  with  the  managers'  approval,  their  compensation,  and  discharge  any 
of  them  at  his  sole  discretion  ;  but  in  every  case  of  discharge  he  shall  forthwith  reeoi"d 
the  same,  with  the  reasons,  under  the  proper  heading  in  one  of  the  books  of  the 
asylum.  He  shall  also  have  the  power  to  suspend  until  the  next  meeting  (monthly)  of 
the  managers,  for  good  and  sufficient  cause,  any  resident  officer ;  but  in  such  case  he 
shall  give  written  notice  to  the  effect,  with  its  cause  and  circumstances,  to  one  of  the 
managers,  whose  duty  thereupon  shall  be  to  call  a  special  meeting  of  the  board  to 
provide  for  the  exigency.  He  shall  also,  from  time  to  time,  give  such  orders  and  in- 
structions as  he  may  judge  best  calculated  to  insiu-e  good  conduct,  fidelity,  and  econ- 
omy in  every  department  of  labor  and  expense  ;  and  he  is  authorized  and  enjoined  to 
maintain  salutary  discipline  among  all  who  are  employed  bj^  the  institution,  and  to 
enforce  strict  compliance  with  such  instructions  and  uniform  obedience  to  all  rules 
and  regulations  of  the  asylum.  He  shall  cause  a  fixll  and  fair  account  and  record  of  all 
his  doings,  and  of  the  entire  business  and  operations  of  the  institution,  to  be  kept 
regularly  from  day  to  day  in  a  book  provided  for  that  purpose,  in  the  manner  and  to 
the  extent  prescribed  in  the  by-laws ;  and  he  shall  see  that  all  such  accounts  and 
records  are  fully  made  up  to  the  last  day  of  December  in  the  year,  and  that  the 
principal  facts  and  results,  with  reports  thereon,  be  presented  to  the  managers  imme- 
diately thereafter.  The  assistant  physician  shall  pei-form  his  duties  and  be  subject  tO' 
the  responsibilities  of  the  superintendent  in  his  sickness  or  absence. 

Sec.  36. — Discharge  of  Patients. 

.  .  .  The  managers,  upon  the  superintendent's  certificate  of  complete  recovery, 
may  discharge  any  jjatient  except  those  under  criminal  charge  or  liable  to  be  removed 
to  prison ;  and  they  may  send  back  to  the  poorhouse  or  township  of  the  county  from 
whence  he  came  any  person  admitted  as  dangerous  who  has  been  two  years  in  the 
asylum,  upon  the  superintendent's  certificate  that  he  is  harmless  and  will  probably 
continue  so,  and  not  likely  to  be  improved  by  further  treatment  in  the  asylum ;  or, 
when  the  asylum  is  full,  upon  the  certificate  that  he  is  manifestly  incurable  and  can 
probably  be  rendered  comfortable  at  the  poorhouse.  They  may  also  discharge  and  de- 
liver any  patient,  except  one  under  criminal  charge  as  aforesaid,  to  his  relatives  or 
friends  who  will  undertake,  with  good  and  approved  securities,  for  his  peaceable  be- 
havior, safe  custody,  and  comfortable  maintenance  without  further  public  charge. 


Ill 


J  IT  EX  nix.  CCi 

Sec.  21. — rrocccdings  ivhcn  LiDiaticn  are  Dangerous  if  at  Large. 

That  it  shall  be  and  may  be  lawful  for  any  two  justices  of  the  peace  of  the  county 
111  which  any  lunatic,  furious,  mad,  or  dangerous,  if  permitted  to  go  at  large,  shall  be 
found,  by  warrant  under  tlieir  liauds  and  seals,  to  direct  tlie  Overseers  or  Overseer  of 
the  Poor  of  the  city  or  township  in  wliich  such  lunatic  or  mad  person  may  be  found, 
to  cause  such  person  to  be  apprclicndcd  and  kept  safely  locked  up,  and  chained  if 
necessary,  in  some  secure  jilace  within  such  city  or  township  or  within  tlie  county 
within  which  said  city  or  township  shall  be  situated,  as  sucli  justices  shall  by  their 
warrant  appoint,  in  case  the  legal  settlement  shall  be  in  the  city  or  township  in  the 
said  county. 

New  Mexico,  1884. 

Sec.  1324. — Judge  may  Issue  a  Commission — When. 

It  shall  be  lawful  for  any  district  judge  in  this  Territory  to  issue  a  commission,  in 
term  or  vacation  time,  in  the  nature  of  a  writ  de  Iiinalico  iiit/uircudo,  to  inquire  into 
the  lunacy  or  habitual  drunkenness  of  any  person  within  tJiis  Territory,  or  having 
real  or  ])ersonal  estate  therein.  Such  commission  shall  issue  in  the  county  wherein 
he  last  had  his  residence,  or  in  which  his  property  is  situated,  and  shall  be  executed 
therein. 

Sec.  1327. — Order  made  to  Court. 

It  shall  be  the  duty  of  the  court,  at  the  time  of  granting  any  application  as  afore- 
said, to  make  such  order  respecting  notice  of  the  execution  of  the  commission  to  the 
party  with  respect  to  whom  such  commission  shall  be  issued,  or  to  some  of  liis  near 
relations  or  friends  who  are  not  concerned  in  the  application,  as  the  said  court  shall 
deem  advisable. 

Sec.  1328. — Jury  of  Inquest. 

It  shall  be  lawful  for  the  commissioner  or  commissioners  to  direct  an  order  to  the 
sheriff,  requiring  him  to  summon  not  less  than,  nor  more  than  twelve  persons  upon  the 
inquest,  as  the  circumstances  to  them  may  seem  to  require. 

Sec.  1329. — I)uiuisition — JThcn  Held. 

If  the  court  shall  be  of  the  opinion  that  the  person  with  respect  to  whom  proceed- 
ings are  instituted  has  no  estate,  or  not  suflicient  to  justify  tlie  expense  of  a  com- 
mission and  the  proceedings  under  it,  the  judge  thereof,  in  person,  shall  hold  said 
commission  during  the  term  of  the  court,  and  shall  direct  an  inquest  to  be  impaneled 
from  the  jurors  attending  said  court,  and  which  proceeding  shall  have  like  force  and 
effect  as  an  inquisition  held  by  commissioners  as  aforesaid. 

Sec.  1354. — Jailer  to  Give  Notice. 

If  any  person  arrested  or  imprisoned  as  aforesaid,  in  any  civil  action,  shall  appear 
to  be  of  unsound  mind,  it  shiiU  be  the  duty  of  the  jailer  or  keeper  of  the  prison  forth- 
with to  give  notice  of  tlie  fact  to  two  justices  of  the  peace,  who  shall  within  live  days 
attend  at  the  prison,  and,  upon  the  oath  or  affirmation  of  such  persons  as  tliey  shall 
think  fit  to  examine,  proceed  to  inquire  into  the  state  of  mind  of  sucli  prisoner,  and  if 
they  shall  iind  him  to  be  a  lunatic  as  was  alleged,  they  shall  forthwith  make  a  record 
of  the  fact  and  certify  the  same  to  the  clerk  of  the  District  Court. 


Revised  Statutes  of  New  York,  1889. 

Chapter  446,  Article  1,  Section  1.— Commitment  of  the  Insane. 

No  person  shall  be  committed  to  or  confined  as  a  patient  in  any  insane  asylum, 
public  or  private,  or  any  institution,  home,  or  retreat  for  tlie  care  and  treatment  of 
insane,  except  upon  the  certificate  of  two  physicians,  uiuler  oath,  setting  forth  the 
insanity  of  such  person.  No  person  shall  be  held  in  confinement  in  any  such  asylum 
for  more  than  five  days,  unless  within  that  time  such  certificate  be  apjiroved  by  a 
judge  or  justice  of  a  court  of  ret-ord  of  the  county  or  district   in  which   the  alleged 


662  ArFEXDix. 

lunatic  resides ;  and  sueli  judge  or  justice  may  institute  inquiiy  and  make  proofs  as  to 
the  fact  of  alleged  lunacy  before  approving  or  disappro%-ing  such  certificate  ;  and  such 
judge  or  justice  may  in  his  discretion  call  a  jury  in  each  ease  to  determine  the  ques- 
tion of  lunacy. 

Sec.  2. — It  shall  not  be  la^wful  for  any  physician  to  certify  to  the  insanity  of  any 
person  for  the  purpose  of  securing  their  commitment,  unless  the  physician  be  of 
reputable  character  and  a  gi'aduate  of  some  incorporated  medical  college,  a  permanent 
resident  of  the  State,  and  shall  have  been  in  actual  practice  of  his  profession  for  at 
least  three  years ;  and  such  qualifications  shall  be  certified  to  by  a  judge  of  any  coui't 
of  record.  Xo  certificate  of  insanity  shall  be  made  exce^it  after  the  personal  exam- 
ination of  the  party  alleged  to  be  insane,  and  according  to  the  fonns  prescribed  by 
the  State  Commissioner  of  Liinacy,  and  every  such  certificate  shaU  bear  a  date  not 
more  than  ten  days  prior  to  such  commitment. 

Sec.  3. — It  shall  not  be  la^^vful  for  any  physician  to  certify  to  the  insanity  of  any 
person  for  the  purpose  of  committing  him  to  an  asyliun  of  which  the  said  physician  is 
either  supeiintendent,  proprietor,  or  officer,  or  a  regular  professional  attendant 
therein. 

Sec.  4. — Every  superintendent  of  the  State  asylum,  or  public  or  private  asylum, 
institution,  home,  or  retreat  for  the  care  and  treatment  of  insane,  shall,  within  thi-ee 
days  after  the  reception  of  any  patient,  make,  or  cause  to  be  made,  a  description  of 
such  case,  entered  in  a  book  exclusively  set  apart  for  that  pm-pose,  and  shall  also 
make  entries  from  time  to  titae  mentioning  state,  bodily  condition,  and  medical 
treatment  of  such  patient,  together  with  the  forms  of  restraint  employed  during  the 
time  such  patient  remains  under  his  care ;  and  in  the  event  of  discharge  or  death  of 
such  patient  the  superintendent  aforesaid  shall  state  in  his  ease-book  the  circum- 
stances pertaining  thereto. 

Sec.  10. — Any  overseer  of  the  poor,  constable,  keeper  of  jail,  or  other  persons  who 
shall  confine  any  lunatic  in  any  seminary,  or  any  other  places  than  such  as  are  herein 
certified,  shall  be  deemed  guilty  of  a  misdemeanor,  and  on  conviction  thereof  shall  be 
liable  to  a  fine  not  exceeding  two  hundred  and  fifty  dollars,  or  imprisonment  not  ex- 
ceeding one  year,  or  both,  at  the  discretion  of  the  court  before  which  the  conviction 
shall  be  had. 

Sec.  33. — When  any  person  confined  under  the  indictments  of  arson,  mui-der  or 
attempt  to  murder,  or  highway  robbery,  or  who  has  been  acquitted  thereof  on  the 
grotxnd  of  insanity,  and  has  been  committed  to  some  State  lunatic  hospital,  .  •  .  shall 
be  restored  to  his  right  mind,  it  shall  be  the  duty  of  the  supei-intendent  of  such  asylum 
to  give  notice  thereof  to  the  State  Commissioner  of  Lunacy,  who  shall  thereupon  in- 
quire into  the  truth  of  the  fact,  and  if  the  same  shall  be  proved  to  his  satisfaction  he 
shall  issue  certificate,  dated  under  his  official  hand  and  seal,  to  a  justice  of  the  Su- 
preme Coiu't  of  the  district  in  which  such  asylum  is  situated,  who  shall  thereupon  and 
upon  such  other  facts  as  may  be  proven  before  him  determine  whether  it  is  safe,  legal, 
and  right  that  such  party  in  confinement,  as  aforesaid,  shall  be  discharged. 

Sec.  24. — Discharge  of  Patients. 

The  managers,  upon  the  superintendent's  certificate  of  complete  recovery,  may 
discharge  any  patient,  except  when  under  a  criminal  charge  or  liable  to  be  remanded 
to  prison,  and  they  may  discharge  any  patient  admitted  as  "  dangerous,"  or  any  patient 
sent  to  the  asyhmi  by  the  superintendent  or  Overseers  of  the  Poor,  or  by  the  (first) 
judge  of  the  county,  upon  the  certificate  of  the  superintendent  that  he  or  she  is  harm- 
less, and  will  probably  continue  so,  and  not  likely  to  be  improved  by  fiu-ther  treat- 
ment in  the  asylum,  or  when  the  asylum  is  full,  upon  a  like  certificate  that  he  or  she 
is  manifestly  inem-able  and  can  probably  be  rendered  comfortable  at  the  poorhouse, 
so  that  the  preference  may  be  given,  in  the  admission  of  patients,  to  recent  cases,  or 
cases  of  insanity  of  not  over  one  year's  duration.  They  may  discharge  and  deliver 
the  patient,  except  when  under  criminal  charge,  as  aforesaid,  to  his  relatives  or 
fi'iends  wlio  will  undertake,  with  good  and  approved  sureties,  for  his  peaceable  be- 
ha^^or,  safe  custody,  and  comfortable  maintenance  without  further  public  charge. 
And  such  sureties  shall  be  approved  by  the  county  judge  of  the  county  fi-om  which 
said  patient  was  sent.  .  .  .  Upon  the  i)resentation  of  a  certified  copy  thereof  the  man- 
agers may  discharge  such  patient. 


APPENDIX.  GG3 

Code  op  North  Carolina,  1883. 

Sec.  2249. — Superintendent — QHalifications. 

.  .  .  He  shall  be  a  skillful  physician,  educated  to  his  profession,  of  good  moral 
■character,  of  prompt  business  habits,  and  of  kindly  disposition.  He  shall  hold  his 
office  for  six  years  from  and  after  his  appointment,  unless  sooner  ren]o\-ed  .  .  .  for 
inlidelity  to  his  trust,  gross  immorality,  or  incompetency  to  discharge  tlie  duties  of  his 
office,  fulfilled  and  declared,  and  the  proof  thereof  recorded  in  the  books.  .  .  . 

Sec.  2250. — Assistant  Physician. 

Each  Board  of  Directors  shall  appoint  one  or  more  assistant  physicians,  and,  with 
the  advice  and  consent  of  the  superintendent,  prescribe  his  duties.  Every  assistant 
physician  appointed  shall  hold  his  place  for  two  years  from  and  after  the  appointment, 
unless  sooner  removed  by  said  board  for  good  cause,  which  shall  be  specified  and 
recorded  in  their  proceedings. 

Sec.  2253. — Superintendent  to  Control  Officers. 

Such  superintendent  shall  exercise  exclusive  direction  and  control  over  all  subor- 
dinate officers  and  employees  engaged  in  the  service  and  labors  of  his  asylum,  and  he 
may  discharge  such  as  have  been  employed  by  himself  or  his  ijredecessor,  and  shall 
report  to  the  Board  of  Directors  of  the  asylum  the  misconduct  of  all  other  suiaordinates. 

Sec.  2256. — Proceedings  to  Obtain  Admission  to  the  Asylum. 

For  admission  into  the  asylum  for  the  insane  the  following  proceedings  shall  be 
had :  Some  respectable  citizen  residing  in  the  county  of  the  alleged  insane  person 
shall  make  before,  and  file  witli,  the  justice  of  the  peace  of  the  county,  an  affida'snt. 
.  .  .  Upon  the  bringing  of  the  alleged  insane  person  before  the  justice  of  the  peace, 
or  upon  the  return  of  the  precept  with  the  body  of  the  insane  person,  the  justice  shall 
cause  to  be  associated  with  him  one  or  more  justices  of  the  said  county,  who  together 
shall  proceed  to  examine  into  the  condition  of  the  mind  of  the  alleged  insane  person, 
and  shall  take  the  testimony  of  at  least  one  respectable  physician,  and  such  others  as 
they  may  think  proper.  If  any  two  of  the  justices  of  the  peace  shall  be  satisfied  that 
the  person  is  insane,  and  some  friend,  as  he  may  do,  will  not  become  bound  with  good 
security  to  restrain  him  from  committing  injuries,  support  and  take  care  of  him  until 
the  cause  for  confinement  shall  cease,  such  justices  shall  direct  such  insane  person  to 
be  removed  to  the  proper  asylum  as  a  patient,  and  to  that  end  they  shall  direct  a  war- 
rant to  the  shei'iff  or  constable,  and  at  the  same  time  shall  transmit  to  the  proper 
Board  of  Directors,  on  examination  of  the  witnesses,  a  statement  of  the  facts  as  the 
.said  justices  shall  deem  pertinent  to  the  subject-matter.  .  .  . 

Sec.  2259. — Action  of  the  Superintendent  in  Boidttful  Cases. 

"Whenever  an  insane  person  shall  be  conveyed  to  any  as.ylum,  and  the  superin- 
tendent is  in  doubt  as  to  the  propriety  of  his  admission,  he  may  convene  any  three  of 
the  Board  of  Directors  of  his  asylum,  who  shall  constitute  a  board  for  the  purpose  of 
examining  and  deciding  that  such  person  is  a  proper  subject  for  admission,  and  if  a 
majority  of  such  board  shall  decide  so,  such  person  shall  be  received  into  that  asylum  ; 
but  that  a  like  board  may  at  any  time  hereafter  deliver  such  insane  person  to  any 
friend  who  may  become  bound  with  good  seciu'ity  to  maintain  and  take  care  of  him  in 
tlie  same  manner  as  he  might  have  become  bound  under  the  surety  of  tlu^  justice  of 
the  peace. 

Sec.  22G0. — Discharge  of  the  Cured — Eenioval  of  the  Incurables. 

Any  three  of  the  Boai'd  of  Directors  of  any  asyhim,  upon  the  certificate  of  the 
superintendent,  .  .  .  shall  be  a  board  to  discharge  or  remove  from  their  asylum  any 
person  admitted  as  insane  when  such  person  has  become  or  is  fomid  to  be  of  sane 
mind,  or  when  such  person  is  incurable  and  in  the  opinion  of  the  superintendent  his 
being  at  large  will  not  be  injurious  to  himself  or  dangerous  to  the  community;  or  said 
board  may  permit  such  person  to  go  to  tlie  county  of  his  settlement  on  pi'obation, 
when  in  tlie  opinion  of  tlie  said  superintendent  it  will  not  be  injurious  to  liimself  or 
•dangerous  to  tlie  community ;  and  said  board  may  discharge  or  remove  sueli  person 


664  AFPENDIX. 

upon  other  sufficient  cause  appearing  to  them ;  and  whenever  any  such  person  ad- 
mitted as  indigent  may  be  so  discliarged  or  removed,  except  as  sane,  it  shall  be  the 
duty  of  the  sheriff  of  the  county  of  his  settlement  to  convey  such  person  to  his  county 
at  its  expense ;  and  any  indigent  person  discharged  as  sane  shall  receive  from  such 
asylum  a  sum  of  money  sufficient  to  pay  his  transportation  to  the  county  of  his  settle- 
ment, which  sum  shall  be  repaid  by  said  county. 


Acts  of  Ohio, 
Sec.  1. — Application  for  Admission  to  tlie  Asylum. 

Be  it  enacted  by  the  General  Assembly  of  the  State  of  Ohio  that  section  705  of 
the  Revised  Statutes  of  Ohio  be  amended  so  as  to  read  as  follows  : 

Probate  judge  ujjon  receiving  certificate  of  medical  witnesses  .  .  .  shall  forthwith 
apply  to  the  superintendent  of  the  hospital  for  the  insane  situated  in  the  district  in 
which  the  patient  resides ;  he  shall  at  the  same  time  transmit  copies  under  his  official 
seal  of  the  certificate  of  the  medical  witnesses  and  of  his  findings  in  the  case.  Upon 
receiving  application  for  certificate,  the  superintendent  shall  immediately  advise  the 
probate  judge  whether  the  patient  can  be  received,  and,  if  so,  at  what  time  ;  the  pro- 
bate judge,  when  ad^dsed  that  the  patient  will  be  received,  shall  forthwith  issue  his 
warrant  to  the  sheriff,  commanding  him  forthwith  to  take  charge  of  and  convey  such 
insane  person  to  the  asylum.  .  .   . 

Sec.  709. — Discharge  of  Patients  from  the  Insane  Asylum. 

...  On  consent  and  ad^^ce  of  the  trustees  the  superintendent  may  discharge  any 
patient  from  any  asylum  for  the  insane,  when  he  deems  such  discharge  proper  and 
necessary ;  provided,  no  patient  with  known  homicidal  or  suicidal  propensities  shall 
be  discharged  without  a  bond  in  the  sum  of  one  thousand  dollars,  with  two  or  more 
sm-eties,  to  be  approved  by  the  probate  judge  of  the  county  of  which  the  patient  is  an 
inhabitant,  payable  to  any  person  who  shall  be  injured  in  person  or  property  by  any 
insane  act  of  such  discharged  person  while  at  large. 

Any  incurable  or  harmless  patients  may  be  discharged  to  make  room  for  acute 
cases  from  the  same  cormty ;  and  no  patient  vdih  known  homicidal  or  suicidal  pro- 
pensities shall  be  hereafter  kept  in  any  county  infirmary  or  jail  of  the  State,  except 
temporarily,  while  awaiting  the  order  for  removal  to  the  State  Asylum  for  the  Insane. 
"When  in  the  opinion  of  the  superintendent  the  condition  of  the  patient  at  the  time  of 
discharge  is  such  as  to  justify  sucli  action  he  may  permit  such  patient  to  go  to  his 
home  or  leave  the  institution  unattended ;  and  if  such  patient  is  not  financially  able 
to  bear  his  own  expenses  the  superintendent  of  the  institution  may  fui'nish  the  patient 
a  sufficient  sum  to  pay  his  traveling  expenses,  and  charge  the  same  to  the  current  ex- 
pense fund  of  the  institution ;  such  sum  shall  in  no  one  case  exceed  twenty  dollars.  .  .  . 

Sec.  704. — Certificates  of  Medical  Attendants. 

At  the  time  (unless  for  good  cause  the  investigation  is  adjourned)  the  judge  shall 
proceed  to  examine  the  witnesses  in  attendance ;  and  if  upon  reading  the  testimony 
he  is  satisfied  that  the  person  so  charged  is  insane,  he  shall  cause  a  certificate  to  be 
made  out  by  the  medical  witnesses  in  attendance.  .   .  . 

Sec.  710. — When  Discharged  as  Cured. 

When  a  patient  is  discharged  as  cured  the  superintendent  may  furnish  such 
patient  with  suitable  clothing  and  a  sum  of  money  as  he  deems  fit,  not  in  any  case 
exceeding  twenty  dollars. 

Sec.  712. — Proceedings  when  Person  Becomes  Again  Insane. 

When  a  patient  discharged  from  an  asylimi  for  the  insane  as  cured  again  becomes 
insane,  and  a  respectable  physician  files  with  the  judge  of  probate  of  the  county  of 
which  the  insane  person  is  an  inhabitant  an  affidavit  setting  forth  the  fact  of  the 
recurrence  of  the  disease,  and  such  other  facts  relating  tliereto  as  he  deems  proper, 
the  probate  judge  shall  forthwith  transmit  a  copy  of  such  affidavit,  authenticated  by 
his  official  seal,  to  the  superintendent  of  the  proper  asylum^  and  thereupon  the  same 


APPENDIX.  GG5 

proceeding  shall  bo  had  as  provided  in  this  chapter  for  persons  found  to  he  insane 
upon  inquest  for  that  purpose. 

Sec.  715. — When  Patient  iJieii,  Ilclaiivcs  nUull  he  Notified. 

When  a  patient  dies  in  any  one  of  the  asylums  for  the  insane,  the  superintendent 
thereof  shall  immediately  notify  relatives  of  such  deceased  patient,  if  known  to  him  ; 
and,  if  not  so  known,  he  shall  immediately  notily  the  probate  jud<<e  of  the  county  from 
which  such  patient  was  sent,  who  shall  forthwith  cause  a  notice  of  his  death  to  be 
printed  in  two  of  the  leading  papers  published  in  the  county. 

Sec.  7.jG. — Qualifications  for  Admission. 

The  asylum  shall  be  open  for  admission  of  all  persons  over  seven  yea^s  ha\'ing  a 
legal  settlement  in  the  county  of  Hamilton ;  but  7io  person  shall  be  entitled  to  admis- 
sion unless  he  become  insane  after  acquiring  a  legal  settlement  therein. 

Sec.  740. — Examination — Physiciu)i's  Certificate. 

At  the  time  appointed  (unless  for  good  cause  the  investigation  is  adjourned)  the 
judge  shall  proceed  to  examine  the  witnesses  in  attendance,  and  if  upon  the  hearing 
of  the  testimony  such  judge  is  satisfied  that  the  person  so  charged  is  insane,  and  is 
included  in  the  class  enumerated  in  this  chapter,  he  shall  cause  a  certificate  to  be 
made  out  by  the  physician,  setting  forth  the  name,  age,  residence  of  patient,  with  a 
concise  history  of  the  case,  medical  treatment  iJiirsued,  supposed  cause  of  disease, 
and  such  other  information  as  is  deemed  useful. 

Sec.  741. — Patient  shall  be  Taken  to  the  Asylum. 

The  probate  judge,  iipon  reeei-vdng  the  certificate  aforesaid,  shall  forthwith  trans-' 
mit  a  co^jy  thereof,  and  his  finding  in  the  case,  under  his  official  seal,  to  some  suitable 
person  (giving  the  relatives  of  the  insane  person  the  preference),  who  shall  imme- 
diately take  charge  of  and  convey  such  patient  to  the  asylum,  and  return  therefor  to 
the  probate  judge  a  receipt  of  the  superintendent,  to  be  filed  with  the  other  papers  in 
"the  case. 

Laws  of  Oregon,  1887. 

Sec.  3555. — Superintendent  to  MaJce  Pay-rolls  of  the  Employees. 

At  the  end  of  each  month  the  superintendent  shall  cause  a  pay-roll  to  be  made,  on 
"which  is  written  the  name  of  each  person  emplo^-ed  in  or  about  the  asylum,  gi\'ing  the 
capacity  in  which  each  is  employed,  the  rate  of  salary  or  wages,  and  the  amount  due 
each.  Upon  recei^^ng  this  pay-roll,  duly  receipted  by  the  superintendent  and  audited 
by  the  board,  the  secretary  of  the  State  shall  draw  his  w^arrant  on  the  treasury  in 
pajTuent  of  the  several  amounts  audited  and  allowed  by  the  board,  and  in  favor  of 
the  person  to  whom  the  same  is  allowed,  in  a  like  manner  as  their  warrants  are  dra-mi 
for  the  payment  of  claims  against  the  State. 

Sec.  3557. — Judge  of  the  County  to  Hear  and  Determine  Complaint  of  Insanity. 

The  county  judge  of  any  county  in  this  State  shall,  upon  application  stated  in 
writing,  setting  forth  that  any  person  or  persons,  by  reason  of  insanity  or  idiocy,  is 
suffering  from  neglect,  exposure,  or  otherwise  is  imsafe  to  be  at  large,  or  is  suffering 
under  mental  derangement,  shall  cause  such  person  or  persons  to  be  brought  before 
him  at  such  time  and  place  as  he  may  direct ;  and  the  said  county  judge" shall  also 
cause  to  appear  at  the  same  time  and  place  one  or  more  competent  })hysicians,  who 
shall  proceed  to  examine  the  person  or  persons  alleged  to  be  insane  or  idiotic  ;  and  if 
said  physician  or  physicians,  after  careful  examination,  shall  certify  upon  oath  that 
such  person  or  persons  are  insane  or  idiotic,  as  the  case  may  be,  then  such  judge  shall 
cause  the  said  insane  or  idiotic  person  to  be  conveyed  to  and  placed  in  the  Insane 
Asylum  of  the  State  of  Oregon.  ... 

Sec.  3553. — Sujierinfendent  as  the  E.vecutire  Officer. 

The  superintendent  shall  be  tlie  executive  officer  of  the  asylum  under  the  regula- 
tions and  by-laws  of  the  Board  of  Trustees.     He  shall  have  control  of  the  patients, 


(566  APPENDIX. 

prescribe  their  treatment,  adopt  necessary  measures  for  their  welfare,  and  discharge- 
such  as  in  his  opinion  liave  permanently  recovei'ed  their  reason,  or  such  other  patients 
as  the  best  interests  of  the  State  and  the  institution  require.  He  shall  maintain  dis- 
cipline among  the  subordinate  officers  and  employees,  and  enforce  obedience  to  the 
laws,  rules,  and  regulations  adopted  for  the  government  of  the  institution ;  and  is 
empowered  to  discharge  any  employee  or  attendant  for  violation  of  the  laws  or  rules 
of  the  asylum,  and  submit  the  same  to  the  Board  of  Trustees  immediately  for  their 
approval.  He  shall  remit  to  the  Board  of  Trustees  a  report  of  the  amount,  kind,  and 
quantity  of  furniture  and  household  furnishing  goods,  provisions,  fuel,  forage,  cloth, 
and  other  material  required  for  six  months  ending  on  the  first  day  of  June  and  Decem- 
ber of  each  year,  and  the  trustees  shall  then  advertise,  when  practicable,  for  four 
successive  weeks,  for  contracts  for  furnishing  said  supplies,  or  so  much  thereof  as 
they  deem  necessary.  .  .  .  Necessary  expenditures  other  than  for  provisions,  fuel, 
forage,  clothing,  and  furniture  and  household  furnishing  goods  may  be  made  lay  the 
superintendent  subject  to  the  approval  of  the  board.  .  .   . 

Sec.  3554. — Siqyerintendent  to  Keep  Accurate  Accounts  and  Make  Monthly  Reports. 

The  superintendent  shall  cause  accurate  and  careful  accounts  to  be  kept  of  the 
daily  expenditures  of  all  classes  of  stores  and  property  placed  in  his  charge,  and  shall 
at  the  end  of  each  month  submit  the  same  to  the  trustees  for  their  inspection,  and  on 
each  daily  report  shall  be  shown  the  number  of  persons  having  lodging  in  the  asylum, 
whether  as  officer,  employee,  or  patient.  .  .  . 


Laws  of  Pennsylvania,  1873. 

Sec.  1. — On  what  Evidence  Insane  Persons  may  be  Placed  in  an  Asylum. 

Insane  persons  may  be  placed  in  a  hospital  for  the  insane  by  their  legal  guardians, 
...  or  by  their  relatives  or  friends  in  case  they  have  no  guardians,  but  not  without 
the  certificate  of  two  or  more  reputable  physicians  under  a  personal  examination  made 
within  one  week  of  the  date  thereof ;  and  this  certificate  to  be  duly  acknowledged  and 
sworn  to  or  affirmed  before  some  magistrate  or  judicial  officer,  who  shall  eertifj^  to  the 
genuineness  of  the  signatures  and  to  the  responsibility  of  the  signers. 

Sec.  13. — Philadelpliia  State  Lunatic  Asylum  Physician. 

.  .  .  The  trustees  shall  have  charge  of  the  general  interests  of  the  institution ; 
they  shall  appoint  a  superintendent  who  shall  be  a  skillful  physician,  subject  tO' 
removal  or  reelection  no  oftener  than  the  period  of  ten  years,  except  by  infidelity  to 
the  trust  reposed  in  him,  or  for  incompetency ;  said  physician  shall  also  reside  in  the 
asylum,  and  shall  be  a  married  man,  and  his  family  shall  reside  with  him.  .  .  . 

Sec.  14. — Powers  of  the  Superintending  Physician. 

The  superintending  physician  shall  appoint  and  exercise  entire  control  over  sub- 
ordinate officers  and  assistants  in  the  institution,  and  shall  have  entire  discretion  of 
the  duties  of  the  same. 

Laws  of  Pennsylvania,  1883. 

Sec.  19. — Time  loithin  which  Certificate  must  he  Made. 

The  certificate  above  provided  for  shall  have  been  made  out  within  one  week  of 
the  examination  of  the  patient,  and  within  two  weeks  of  the  time  of  the  admission  of 
the  patient,  and  shall  be  duly  sworn  to  or  affirmed  before  a  judge  or  magistrate  of  this 
commonwealth  and  of  the  county  where  such  person  has  been  examined,  who  shall 
certify  to  the  genuineness  of  the  signatures  and  to  standing  and  good  repute  of  all 
the  signers ;  and  any  person  falsely  certifying  as  aforesaid  shall  be  guilty  of  misde- 
meanor and  also  liable. 

Sec.  23. — Duty  of  Medical  Attendant. 

.  .  .  The  regular  medical  attendant  of  the  house  shall,  within  twenty-four  hours 
after  the  reception  of  any  patient,  examine  such  patient  and  reduce  to  writing  the- 


APPENDIX.  667 

results  of  such  an  exainiuation,  and  enter  the  same  upon  the  hook  to  be  kept  for  the 
])urpose,  with  tlie  opinion  fovincd  from  sucli  examination  and  from  the  documents 
received  with  the  patient. 

>Sec.  1^4.  —  ll'licii  Dclcitlioii  Unnecessary,  Notice  to  be  Given. 

In  case  the  said  incdiciil  attendant  is  of  the  opinion  that  detention  is  not  necessary 
for  the  benefit  of  tlie  patient,  he  shall  notify  tlie  person  or  persons  at  whose  instance 
the  patient  is  detained,  and  unless  sucli  a  jjerson  shall  witliout  a  delay  not  exceeding 
seven  days  ex]nl)it  satisfactory  proof  of  such  necessity,  the  patient  shall  be  discharged 
from  the  house  and  restored  to  his  family  or  friends. 

Sec.  25. — Intervicivs  AUnivcd. 

At  the  time  of  such  examination  the  medical  attendant  shall  himself  cause  tlie 
patient  strictly  to  rmderstand,  if  he  or  she  is  capable  of  doing  so,  that  if  he  or  she 
desires  to  see  or  otherwise  connuunicate  with  any  person  or  persons,  means  will  be 
provided  for  such  interview  or  communication,  and  said  attendant  shall  see  that  the 
proper  means  are  taken  to  communicate  this  fact  to  the  person  or  persons  indicated 
by  the  patient ;  or  any  proper  person  or  persons  not  exceeding  two  shall  be  permitted 
to  have  a  full  unrestrained  interview  with  the  patient. 

Sec.  26. — Reports  to  he  Made  hij  the  Medical  Attendant. 

The  statement  furnished  at  the  time  of  the  reception  of  the  patient  (and  of  the 
examination  of  the  patient  by  the  medical  attendant  of  the  house)  shall  be  forwarded 
by  mail  to  the  address  of  the  Committee  on  Lunacy  within  seven  days  from  the  time 
of  the  reception  of  the  patient,  which  shall  by  them  be  entered  in  a  book  which  shall 
be  kept  for  the  purpose,  and  at  least  once  in  six  months  there  shall  be  reports  made 
by  the  medical  attendant  of  the  house  on  the  condition  of  the  patient,  together  with 
such  other  matters  relative  to  the  case  as  the  said  committee  may  require ;  and  at  the 
same  time  such  report  shall  be  made  by  request  of  the  secretary  of  the  Committee  on 
Lunacy. 

Sec.  28. — Materials  for  Correspondence,  etc. 

All  persons  detained  as  insane  shall  be  furnished  with  materials  and  reasonable 
opportunity,  under  the  discretion  of  the  superintendent  or  manager,  for  communicat- 
ing, under  seal,  without  the  building,  and  such  comnmnieation  shall  be  stamped  and 
mailed.  They  shall  have  the  unrestrained  privilege  of  addressing  communications,  if 
they  so  desire,  not  oftener  than  once  a  month,  to  any  member  of  tlie  Committee  on 
Lunacy. 

Sec.  31. — Persons  Restored  to  Reason  to  he  FortJucith  Discharged. 

All  persons  that  have  been  detained  as  insane  (other  than  criminal  insane  duly 
convicted  and  sentenced  by  a  court)  shall,  as  soon  as  they  are  restored  to  reason  and 
are  competent  to  act  for  themselves,  in  the  opinion  of  the  medical  attendant  of  the 
house,  be  forthwith  discharged ;  and  any  person  so  detained  shall  at  all  times  be  en- 
titled to  a  writ  of  habeas  corpus  for  the  determination  of  this  question.  ...  In  case 
the  discharged  patient  be  in  indigent  circumstances,  such  person  shall  be  furnished 
with  necessary  raiment  and  with  funds  sufficient  for  sustenance  and  travel  to  his 
home,  to  be  charged  to  the  county  from  which  such  patient  was  committed. 

Sec.  32. — Committee  to  he  Notified  of  Discharges. 

The  Committee  on  Lunacy  shall  be  notified  of  all  discharges  within  seven  days 
thereafter,  and  a  record  of  same  shall  be  kept  by  the  committee. 

Sec.  :}6.— Postal  Privileges  of  the  Patients. 

..."  That  it  shall  be  unlawful  and  be  deemed  a  misdemeanor  in  law,  punishable 
by  fine  not  exceeding  one  hundred  dollars,  for  any  superintendent,  officer,  physician, 
or  other  employee  of  any  insane  asylum,  to  intercept,  delay,  or  interfere  mth,  in  any 
manner  whatsoever,  the  transmission  of  any  letter  or  other  written  communication 
addressed  by  an  inmate  of  anj'  insane  asylum  to  his  or  her  counsel  residing  in  the 
county  in  wliich  the  home  of  the  patient  is,  or  the  State  or  county  in  which  the  asylum 
is  located,"  is  hereby  amended  so  that  the   same   shall   extend  to  superintendents, 


6G8  APFENDIX. 

offieei's,  servants,  or  other  employees  of  all  hospitals,  houses,  or  places  which  are  sub- 
ject to  the  provision  of  this  act. 


Statutes  of  Rhode  Island,  May,  1884 — January,  1885. 

Chapter  479. — Apportionment  of  Insane  Paupers  at  the  Butler  Hospital  or  other  Curative 

Hospitals. 

Whenever  it  shall  appear  by  the  written  certificate  of  two  practicing  physicians 
of  good  standing  that  any  pauper  within  the  State  is  insane,  and  may  be  benefited  by 
curative  treatment,  the  agent  of  State  Charities  and  Corporations,  with  the  "written 
consent  of  the  govei'nor,  may  place  such  insane  pauper  in  the  Butler  Hospital  for  the 
Insane ;  but  in  case  such  pauper  cannot  be  received  in  the  said  hospital,  then  at  some 
public  curative  hospital  for  the  insane  within  the  State. 

Public  Statutes  of  Rhode  Island,  1882. 

Chapter  74,  Section  1. — Whenever  complaint  in  writing  and  under  oath  shall  be 
made  to  any  trial  justice  or  clerk  of  a  justice  court,  that  any  person  within  the  county 
is  a  lunatic,  or  so  furiously  mad  as  to  render  it  dangerous  to  the  place  or  safety  of  the 
good  people  of  the  State  for  him  to  be  at  large,  and  that  such  person  is  at  large,  such 
trial  justice  or  clerk  shall  issue  his  warrant,  under  his  hand  and  seal  and  returnable 
forthwith,  directed  to  the  dejjuty  sheriffs,  town  sergeants,  or  constables,  requiring 
the  officer  charged  therewith  to  apprehend  such  person,  and  convey  him  with  such 
warrant  before  such  or  some  other  Justice  Court  for  examination  relative  to  such  com- 
plaint. 

Sec.  2. — Examination  and  Proceedings  onMeturn  of  tlie  Warrant  and  Commitment  of  the 

Mad  Person. 

If  the  court  on  such  examination  shall  adjudge  such  comj)laint  to  be  true,  it  shall, 
unless  a  recognizance  satisfactory  to  said  coiirt  be  then  given  before  it  that  said  per- 
son shall  not  be  permitted  to  go  at  large  until  restored  to  soundness  of  mind,  commit 
such  person  by  warrant  imder  its  hand  and  seal  to  the  Butler  Hospital  for  the  Insane, 
or  to  the  State  Hospital  for  the  Insane,  there  to  be  detained  until,  in  the  judgment  of 
some  justice  of  the  court  of  the  county  in  which  he  may  be  detained,  he  shall,  upon 
inspection  and  examination,  be  declared  to  be  restored  to  soundness  of  mind,  or  to  be 
no  longer  under  the  necessity  of  restraint,  or  imtil  recognizance  as  aforesaid,  satis- 
factory to  such  court,  shall  be  given. 

Sec.  10. — When  a  Person  Committed  may  he  Discharged  though  not  Cnred. 

Any  person  committed  to  any  such  institution  under  the  previous  proceedings  of 
tlie  fourth  section  may,  although  not  restored  to  sanity,  be  discharged  therefrom  upon 
the  written  recommendation  of  the  trustees  and  superintendent  thereof,  or  an  order  of 
any  justice  of  the  Supreme  Court,  to  be  made  in  his  discretion. 

Sec.  11. — Commitment  of  Lunatics. 

Insane  persons  may  be  removed  to  and  placed  in  the  said  Butler  Hospital  or  State 
Asylum  for  the  Insane,  if  they  can  be  there  received,  and,  if  not,  in  any  other  cura- 
tive liospital  for  the  insane  of  good  repute  in  this  State.  .  .  .  But  the  superintendent 
of  said  hospital  shall  not  receive  any  person  into  his  custody  in  such  case  without  the 
certificate  from  two  practicing  physicians  of  good  standing,  known  to  him  as  such, 
that  such  person  is  insane. 

Sec.  12. — Powers  of  Superintendent  to  Pcceive  ami  Detain  Lunatics. 

Any  person  committed  to  the  charge  of  any  of  the  said  institutions  for  the  insane 
as  aforesaid,  in  either  of  the  modes  herein  described,  may  lawfully  be  received  and 
detained  in  said  institution  by  the  superintendent  thereof,  and  by  his  keeper  and 
servants,  iintil  discharged  bj^  any  one  of  the  modes  herein  provided;  and  no  super- 
intendent, his  keepers  or  servants,  nor  the  trustees  or  agents  of  same,  shall  be  liable, 
^civilly  or  criminally,  for  receiving  or  detaining  such  person  so  committed  or  detained. 


APPENDIX.  GG9 

Sec.  14. — Siq)eriutc)ulent  may  Discharge — JVlien. 

Tlie  superintendent  of  such  institution  for  the  insane  within  the  State  may,  on 
ilie  application  of  any  rehitive  or  friend,  witli  the  proper  approval  in  writing  of  the 
visiting  committee  or  trustees,  discharge  from  such  institution  any  jjatient  not  com- 
mitted by  process  of  law. 

Sec.  30. — To  Visit  Insane  Persons. 

The  State  Commission,  or  either  of  the  members  thereof,  shall  from  time  to  time 
in  their  discretion  visit  every  institution  or  place  wherein  any  person  insane  or  alleged 
to  be  insane  is  restrained  of  his  liberty,  and  alone  or  attended,  as  they  shall  elect, 
-examine  into  the  condition  and  complaint  of  any  one  so  confined. 

Sec.  31. — Duty  of  Persons  in  Charge  of  Insane  Persons. 

The  superintendents,  officers,  keepers,  and  assistants,  and  other  persons  in  charge 
■wherever  any  insane  person  is  confined,  are  forbidden  and  enjoined  fi-om  in  any  way 
or  manner  interfering,  hindering,  or  preventing  anj'  person  so  confined  from  com- 
municating at  all  times,  in  manner  as  aforesaid,  witli  said  commission,  except  under 
consultation,  and  with  the  full  consent  in  writing  of  the  commission.  And  every  such 
superintendent,  officer,  keeper,  and  assistant,  or  other  person,  shall  afford  to  every 
person  under  his  charge,  with  the  exception  of  the  aforementioned,  every  facility  for 
making  such  communications,  according  to  the  true  intent  and  meaning  thereof,  and 
■shall  forward  such  communication  to  the  said  commission  without  delay. 


Laws  op  South  Carolina,  1884-. 

Act  508,  Sfx'.  1. — Certifieate  of  Physicians. 

.  .  .  Physicians  examining  summoned  persons  alleged  to  be  insane  for  admission 
to  a  limatic  asylum  shall  certify  under  oath  that  they  are  registered  in  accordance 
with  tlie  State  law,  that  they  have  examined  the  persons  separately,  and  that  they  are 
not  related  by  blood  or  marriage  to  any  of  the  persons  ;  they  shall  also  certify  under 
oath  that  to  the  best  of  tbeir  medical  knowledge  the  persons  they  recommend  for 
admission  to  the  lunatic  asylum  are  epileptics,  idiots,  or  lunatics,  incurable  at  home, 
and  that  they  are  violent  or  dangerous. 

Sec.  2. — Idiots,  Epileptics,  etc.,  not  to  he  Sent  unless  Violent. 

Physicians  giving  certificates  recommending  commitment  to  the  asylum  of  a  per- 
son who  is  simply  idiotic,  epileptic,  physically  infirm,  or  mentally  imbecile,  imless 
such  person  is  violent  or  dangerous,  shall  be  deemed  guilty  of  a  misdemeanor,  and 
upon  conviction  thereof  shall  be  fined  by  the  District  Coui't. 


Laws  of  1882. 

Act  121,  Sec.  1. — Terms  and  Conditions  upon  which  Patients  may  he  Admitted  into  the 

Asylum. 

.  .  .  The  superintendent  and  regents  of  the  State  Lunatic  Asylum  shall  not  re- 
ceive into  said  institution  any  beneficiary  patient  uidess  the  order  consigning  sucli 
person  to  the  asylum  is  accompanied  by  report  from  the  County  Commissioners  of  the 
county  from  which  such  person  is  sent,  certifying  that  they  have  carefully  investi- 
gated the  circumstances  and  condition  of  such  person,  his  or  her  family,  parent,  or 
guardian,  and  that  such  person  is  a  proper  subject  for  the  beneficiary  care,  and  to 
what  extent. 

South  Carolina  Laws,  1881-82. 

Chapter  64G,  Sec.  1. — How  Lunatics  are  to  be  Sent  to  the  Asylum. 

.  .  .  All  officers  now  authorized  by  law  to  send  insane  persons  to  the  lunatic 
asylum  shall,  before  sending  such  insane  person  to  the  asylum,  notify  the  chairman 


670  APFEyDIX. 

of  the  Board  of  County  Commissioners,  or  the  clerk  of  sneh  "board,  that  such  person 
should  be  sent  to  the  lunatic  asylum,  having  first  had  such  lunatic,  if  of  a  dangerous- 
or  violent  character,  so  secured  as  not  to  do  any  damage  or  injiuy.   .   .  . 

Sec.  1586. — How  to  be  Admitted  to  the  Asyhoii. 

It  shall  be  the  duty  of  the  regency  to  admit  as  subjects  of  the  institution  all  idiots, 
lunatics,  and  epileptics,  under  the  statutes  of  this  State  and  subject  to  the  foUowing^ 
conditions,  that  is  to  say :  ...  (3)  all  persons  who  shall  be  declared  lunatics,  idiots, 
or  epileptics.  After  due  examination  by  one  trial  justice  and  two  licensed  practicing^ 
physicians  of  the  State  where  the  subject  is  a  pauper,  the  admission  shall  be  at  the 
request  of  the  County  Commissioners  wherein  such  pauper  has  a  legal  settlement ; 
otherwise  the  admission  shall  be  at  the  request  of  the  husband  or  wife,  or,  where 
there  is  no  husband  or  wife,  of  the  next  of  kin  of  the  idiot,  lunatic,  or  epileptic. 

Sec.  1588. — Judges  may  Direct  Inquisition. 

Whenever  a  judge  of  probate  or  a  judge  of  the  Cii'cuit  Court  shall  direct  an  order 
to  any  trial  justice  to  inquire  as  to  the  idiocy,  lunacy,  or  epilepsy  of  any  jaerson,  or 
when  information  on  oath  shall  be  given  to  any  trial  justice  that  a  person  is  an  idiot, 
lunatic,  or  epileptic,  and  is  chargeable  for  his  support  on  the  county,  it  shall  be  the 
duty  of  said  trial  justice  forthwith  to  call  to  his  assistance  two  licensed  practicing^ 
physicians,  and  examine  such  person  as  to  e^ndence  of  his  or  her  idiocy,  lunacy,  or 
epilepsy ;  and  if  after  full  examination  they  shall  find  such  person  an  idiot,  lunatic,  or 
epileptic,  they  shall  certify  to  said  judge  or  Board  of  Comity  Commissioners  whether 
in  their  opinion  such  person  is  cui-able  or  incui-able,  and  whether  his  enlargement 
would  be  harmless  or  dangerous  or  annoying  to  the  community;  and  thereupon  the 
judge  or  Board  of  County  Commissioners  in  its  discretion  may  make  an  order  that  the 
said  person  shall  be  sent  to  the  lunatic  asylum. 

Sec.  1594. — Discharge  of  Lunatics. 

"Whenever  any  lunatic  or  epileptic  shall  have  recovered,  it  shall  be  the  dutj'  of  the 
regents  to  discharge  him  from  the  asjdum. 

Sec.  1596. — 111  Treatment  of  Patients  h\j  Employees. 

It  shall  be  the  duty  of  the  regents  to  remove  from  office  and  cause  to  be  indicted 
any  person  employed  in  said  institutions  who  shall  assault  any  idiot,  lunatic,  or 
epileptic  with  any  other  or  greater  violence  than  may  be  necessary  for  his  or  her 
restraint,  government,  or  cm-e. 


Code  of  Tennessee,  1884. 

Article  2,  Section  2027. — Qualifications  of  Snpei-intendent. 

The  superintendent  of  the  hospital  shall  ,be  appointed  by  the  Board  of  Trustees,, 
and  shall  be  a  skillful  physician,  of  unblemished  moral  character,  of  enlightened  and 
thorough  professional  education,  of  prompt  business  habits,  and  of  humane  and  kind 
disposition. 

Sec.  202S.—Eesidcnce,  etc. 

He  shall  be  a  married  man,  and  with  his  family  shall  reside  constantly  in  the 
institution. 

Sec.  2029.— Term  of  Office. 

He  shall  hold  his  office  for  eight  years,  but  may  be  removed  by  the  Board  of  Trus- 
tees for  infidelity  to  his  trust  or  incompetency  fully  shown  and  declared. 

Sec.  20.30.— Po«Tr.s-  over  Officers. 

He  shall  exercise  entire  control  over  all  subordinate  officers  and  assistants  in  the 
hospital,  and  shall  have  entire  direction  of  the  duties  of  same,  he  himself  being' 
accountable  to  the  Board  of  Trustees  for  their  good  character  and  fidelity  in  the  dis- 
charge of  their  duties. 


AL't'ESDlX.  671 


Sec.  2Q'iQ.— Duties. 

It  shall  Ije  the  duty  of  the  superintendent,  under  the  orders  of  the  Board  of  Trus- 
tees :  First,  to  exercise  a  f?eneral  superintendeney  over  all  matters  relating  to  the 
hospital.  Second,  to  visit  the  patients  therein  at  least  twice  a  week,  or  (jttener  if 
necessary.  Third,  to  call  meetings  of  extraordinary  importance  of  the  Board  when- 
ever he  may  deem  it  necessary.  Fourth,  to  report  to  the  trustees  immediately  before 
each  general  assembly,  first,  the  number  of  patients  admitted  into  the  asylum  ;  sec- 
ond, date  of  admission  of  each  patient ;  third,  the  degree  and  kind  of  insanity  with 
which  each  patient  is  afflicted ;  fourth,  length  of  time  each  person  was  supposed  to 
have  been  affected  before  admission ;  fifth,  the  profession,  occupation,  age,  and  habits 
of  each  patient,  and  whether  married  or  single  ;  sixth,  tlie  names  of  those  discharged, 
and  the  condition  of  each  when  discharged;  seventh,  and  such  other  particulars  as  he 
may  deem  necessary  to  fiu-ther  action  and  legislation  thereon. 

Sec.  2037. — In  Reference  to  Removal  of  Patients. 

The  superintendent,  by  authority  of  the  resident  Board  of  Trustees  or  a  majority 
of  them,  shall  have  power  to  require  the  removal  of  any  patient,  paying  or  non-pay- 
ing, whenever  in  their  opinion  it  is  advisable  to  do  so. 


Title  7,  Kevised  Statutes  of  Texas,  1879. 

Article  67. — Board  of  Managers. 

The  general  control  and  management  and  direction  of  the  affairs  of  the  State 
asylums  shall  be  vested  in  the  Board  of  Managers,  to  be  styled  the  "Board  of  Man- 
agers of  the  Lunatic  Asylums." 

Art.  73. — Monthhj  Insjycction. 

One  or  more  of  the  managers  shall  visit  the  asylum  and  inspect  the  same  at  least 
once  every  month. 

Art.  75. — Superintendent  Provided  for. 

The  governor  of  this  State  shall  appoint,  by  and  with  the  ad^dce  and  consent  of 
the  Senate,  a  superintendent  of  the  lunatic  asylum,  who  shall,  unless  sooner  removed, 
hold  his  office  for  a  term  of  two  years ;  and  in  the  case  of  a  vacancy  in  said  office  the 
appointment  shall  be  only  for  the  expiring  term,  and  the  term  of  such  officer  shall,  in 
any  event,  expire  with  the  term  of  the  governor  making  the  appointment. 

Art.  76. — Qualifications  of  the  Superintendent. 

The  superintendent  shall  be  a  married  man,  and  also  of  experience  in  the  treat- 
ment of  insanity.  He  shall  reside  in  the  hospital  with  his  family,  and  shall  devote  his 
whole  time  exclusively  to  the  duties  of  his  office. 

Art.  80. — Powers  and  Duties  of  the  Superintendent. 

The  superintendent  shall  be  the  chief  executive,  medical,  and  disbiu'sing  officer  of 
the  institution,  and  subject  to  the  by-laws,  but  shall  have  general  care  and  control 
over  everything  connected  therewith.  He  shall  attend  to  the  enforcement  of  the  laws 
of  the  State  relating  to  the  asylum,  and  by-laws  of  the  institution,  and  shall  take  care 
that  all  employees  connected  therewith  diligently  and  faithfully  perform  duties  as- 
signed to  them. 

Art.  81. — The  superintendent  shall  also,  with  the  consent  of  the  Board  of  Mana- 
gers, CTuploy  such  officers,  attendants,  and  other  persons  as  may  be  required  for  the 
service  of  the  institution,  and  with  like  consent  may  discharge  them  at  pleasure.  He 
shall  also  receive  and  discharge  patients,  superintend  repairs  and  improvements,  and 
take  care  that  all  moneys  intrusted  to  him  are  judiciously  and  economically  ex- 
jiended. 

Art.  82. — The  superintendent  shall  keep  also  an  accurate  and  detailed  account  of 
all  moneys  received  and  expended  by  him,  certifying  the  source  from  which  such 
moneys  were  received,  and  to  which  and  on  what  account  to  be  xised  ;  and  on  the  first 
day  of  July  of  each  year  he  shall  report  the  same  under  oath  to  the  governor. 


^72  APFEXDIX. 

Art.  83. — The  supermtendent  shall  also  keep  and  register  patients  received  into 
the  asylum  and  discharged  therefi'om,  together  with  a  full  record  of  all  the  operations 
of  the' institution,  and  on  the  first  day  of  November  of  each  year  he  shall  report  such 
operations  in  full  to  the  governor,  accompanied  with  such  suggestions  and  recom- 
mendations concerning  the  management  and  operations  of  the  asylum  as  may  be  deemed 
important. 

Art.  84. — Annual  Inventory . 

On  the  first  day  of  November  of  each  year  the  superintendent  shall  cause  inventory 
of  all  the  personal  property  belonging  to  the  asylum  to  be  prepared,  in  AvMch  inven- 
tory an  estimated  value  shall  be  set  beside  each  article,  and  shall  submit  the  same  to 
the  Board  of  Managei's. 

Art.  92. — Before  any  person  can  be  received  as  a  patient  .  .  .  the  parent  or  legal 
guardian  of  such  person,  or,  in  case  he  has  no  parent  or  guardian,  then  some  near 
relative  or  other  person  interested  in  him,  must  present  a  wi-itten  request  to  the  super- 
intendent for  his  admission,  setting  forth  the  name,  age,  residence  of  the  Itmatie, 
together  with  such  particulars  as  may  be  required  by  the  superintendent  or  the  by-laws 
of°the  institution ;  which  written  request  must  be  under  oath  of  the  party  presenting 
it,  and  be  accompanied  with  an  affidavit  of  the  physician  certifying  to  the  insanity, 
that  he  has  made  a  careful  examination  of  the  person  for  whom  admission  is  applied 
for,  and  verily  believes  him  to  be  insane. 

Art.  93. — County  Judge  must  Certify. 

The  application  referred  to  in  the  preceding  article  must  also  be  accompanied  by 
the  certificate  of  the  county  judge  of  the  county  where  the  lunatic  resides,  that  the 
phvsician  certifying  to  the  insanity  of  the  person  under  charge  is  a  respectable  physi- 
cian in  regular  practice  ;  which  certificate  of  the  county  judge  must  be  attested  by  the 
seal  of  the  County  Court  of  his  eoimty. 

Art.  99. — Discharge  of  Patients. 

Any  patient,  except  such  as  are  charged  with  or  con-^-icted  of  some  offense  and 
liave  been  adjudged  insane  in  accordance  -R-ith  the  pro^-isions  of  the  Code  of  Criminal 
Procedure,  may  be  discharged  from  the  asylum  at  any  time  upon  the  recommendation 
of  the  superintendent,  approved  by  the  Board  of  Managers.  Any  patient  coming 
within  the  above  exception  can  only  be  discharged  by  order  of  the  court  by  which  he 
was  committed. 

Art.  100. — Xo  patient  shall  be  discharged  without  suitable  clothing  and  sufficient 
money  to  pay  his  expenses  home  ;  and  when  a  patient  is  discharged  by  order  of  the 
court  he  shall  be  provided  with  a  suitable  guard  and  conveyed  to  his  fi'iends,  or  to  the 
county  from  which  he  was  sent. 

Art.  106. — Apjirehension  of  Lunatics. 

If  information  written  under  oath  be  given  to  any  county  judge  that  any  person  ui 
his  coxinty  is  a  lunatic  or  non  compos  mentis,  and  that  the  welfare  of  himself  or  of  others 
requii'es  "that  he  be  placed  under  restraint,  and  said  county  judge  shall  believe  such 
information  to  be  true,  he  shall  forthwith  issue  his  warrant  for  the  apprehension  of 
such  person,  and  shall  fix  a  day  for  the  hearing  and  detennination  of  the  matter. 

Art.  120. — Suitable  Clothing  to  he  Provided. 

Before  sending  any  patient  to  the  asylum  the  coimty  judge  shall  take  care  that  the 
patient  is  provided  with  two  full  suits  of  substantial  summer  clothing  and  one  full  suit 
of  substantial  winter  clothing. 


Laws  of  Utah,  1880. 

Chapter  31,  Section  13. — Qualifications  of  the  Medical  Superintendent  and  his 

Duties. 

The  medical  superintendent  shall  be  well  educated,  an  experienced  physician,  and 
a  regular  graduate  in  medicine,  and  .shall  have  practiced  at  least  five  years  fi'om  the 
■date  of  his  diploma.     He  shall  have  the  general  superintendence  of  the  buildings. 


APPENDIX.  673 

grounds,  iiiul  property  tliorcof,  suhjpct  to  the  laws  and  regulations  of  the  directors. 
He  sliall  luive  t-oiitrol  of  the  patients,  ^jreseribe  tlieir  treatment,  adopt  sanitary  meas- 
ures for  their  welfare,  and  diseluirge  sueli  as  in  his  ojjinion  have  permanently  recovered 
their  reason.  He  shall  appoint,  with  the  approval  of  the  directors,  as  many  attendants 
as  may  be  necessary  for  tiie  efficient  and  economic  care  and  management  of  the  asylum, 
and,  with  the  consent  of  tlie  Board  of  Directors,  fix  their  compensation  and  discharge 
any  of  them.  He  shall  prescrilie  tlie  duties  of  the  subordinate  officers,  maintain  dis- 
cipline among  them,  and  enforce  obedience  to  the  laws,  rules,  and  regulations  adopted 
for  tlie  government  of  the  institution.  He  shall  estimate  quarterly,  in  advance,  the 
proV)able  expenses  of  the  asylum,  and  submit  the  same  to  the  Board  of  Directors  at 
their  regular  meeting  preceding  the  commencement  of  sucli  quarter,  for  their  approval. 
.  .  .  TJie  medical  sui)erintendent  sliall  cause  to  be  kept  full  and  accurate  accounts  and 
records  of  his  official  transactions  from  day  to  day,  in  books  provided  for  that  purpose, 
in  the  mode  prescril)ed  in  the  by-laws.  He  shall  see  that  his  accounts  are  fully  made 
xip  to  the  olst  of  December  in  each  year,  and  shall  submit  his  annual  report  to  the 
Board  of  Directors  immediately.  He  shall  visit  the  asylum  every  day  in  the  year,  un- 
less he  obtain  leave  of  absence  from  the  president  of  the  Board  of  Directors,  in  which 
event  the  assistant  physician  shall  discharge  his  duties.  .   .  . 

Sec.  16. — Judge  of  Frohate  may,  if  Found  Necessary,  Direct  that  Insane  Persons  he  Placed 

in  an  Insane  Asylum. 

The  probate  judge  of  any  county  in  this  Territory  shall,  upon  application  under 
oath,  setting  forth  that  a  person,  by  reason  of  insanity,  is  dangerous  to  be  at  large, 
caiise  such  person  to  be  brought  before  him,  and  he  shall  summon  to  appear,  at  the 
same  time  and  place,  two  or  more  witnesses  who  well  knew  the  accused  during  the  time 
of  alleged  insanity,  who  sliall  testify,  under  oath,  as  to  the  conversation,  manners,  and 
general  talk  upon  which  charge  of  insanity  is  based ;  and  shall  also  cause  to  appear  be- 
fore him,  at  the  same  time  and  place,  two  practicing  physicians  in  medicine,  before 
whom  the  judge  shall  examine  the  charged ;  and  if,  after  a  careful  hearing  of  the  ease 
and  a  personal  examination  of  the  alleged  insane  person,  the  said  physicians  shall  cer- 
tify, on  oath,  that  the  person  is  insane,  and  the  case  is  of  recent  or  cui'able  character, 
or  that  the  insane  person  is  of  homicidal,  suicidal,  or  incendiary  disposition,  and  that 
from  any  other  violent  symptoms  the  said  insane  person  would  be  dangerous  to  his  or 
her  own  life,  or  to  the  lives  or  property  of  the  community  in  which  he  or  she  may  live, 
and  the  said  physicians  shall  also  certify  to  the  name,  age,  nativit}^  residence,  occupa- 
tion, length  of  time  in  the  Territory,  State,  or  county  last  from,  previous  habits,  pre- 
monitory symptoms,  apparent  cause,  and  class  of  insanity,  duration  of  the  disease,  and 
present  condition,  as  nearly  as  may  be  ascertained  by  inquiry  and  examination  ;  and 
if  the  judge  shall  be  satisfied  that  the  facts  revealed  in  the  examination  establish  the 
insanity  of  the  person  accused,  and  that  it  is  of  a  recent  or  curable  nature,  or  of  homi- 
cidal, suicidal,  or  incendiary  character,  or  that  from  the  violence  of  the  spuptoms  the 
said  insane  j)erson  would  be  dangerous  to  his  or  her  own  life,  or  to  the  lives  or  property 
of  others,  if  at  large,  he  shall  direct  a  sheriff  of  the  county,  or  some  suitable  person, 
to  convey  to  and  place  in  charge  of  the  officers  of  the  Territorial  Insane  Asylum  such 
person,  and  shall  transmit  a  copy  of  the  complaint  and  commitment,  and  physicians' 
certificate,  which  shall  also  be  in  the  form  furnished  by  the  medical  superintendent  of 
said  asylum.   ... 

Vekmont,  1884. 

Act  No.  52,  Section  1. — It  is  hereby  enacted  by  the  general  assembly  of  the 
State  of  Vermont,  that  section  2898  of  the  Eevised  Laws  is  hereby  amended  so  that 
it  will  read  as  follows  : 

The  supervisors  shall  visit  the  Vermont  Hospital  for  the  Insane  as  often  as  occasion 
requires,  and  one  member  as  often  as  once  a  month,  and  also  any  other  place  where 
insane  persons  are  confined  in  the  State,  at  their  discretion  ;  shall  examine  into  the 
condition  of  the  said  asylum,  and  such  other  places  where  insane  persons  are  confined, 
the  management  and  treatment  of  the  patients  therein,  their  physical  and  mental  con- 
dition, and  medical  treatment ;  form  a  careful  opinion  of  the  patients,  apart  from  the 
officers  and  keepers,  and  investigate  the  cases  that  in  their  judgment  require  special 
investigation,  and  jiarticularly  ascertain  whether  persons  are  confined  in  sxich  nsylnra 
oi'  (itlier  places  who  ought  to  be  discharged.  They  shall  liave  the  general  supervision 
of  the  insane  of  the  State  not  in  confinement,  so  far  as  it  concerns  their  physical  and 


674  AFFEXLIX. 

mental  condition,  their  eare,  management,  and  medical  treatment ;  and  also  those  "who 
are  discharged  from  such  asvlum  or  place  of  confinement  bv  authority  under  section  4 
of  the  act  approved  November  28,  1882,  and  shall  make  such  order  therein  as  such  ease 
requires. 

Eevised  Statutes,  1880. 
Chapter  139,  Section'  2897. — Siq)ervisors. 

The  general  assembly  shall  elect  biennially  three  Supervisors  of  Insane,  who  shall 
hold  their  office  for  two  years,  commencing  on  the  first  day  of  the  next  December  ;  and 
the  governor  may  fill  vacancies  of  the  board  during  the  term.  Two  of  said  supervisors 
shall  be  physicians,  and  none  of  them  shall  be  a  tmstee,  superintendent,  employee,  or 
other  officer  of  an  insane  asylum  in  the  State. 

Sec.  2900. — Powers  of  tlte  SupervisQrs. 

The  supervisors  may  administer  oaths,  summon  witnesses  before  them  in  any  case 
Tinder  investigation,  and  discharge  by  their  orders  in  wi-itiug  any  person  confined 
as  a  patient  in  any  asylum  for  the  insane  whom  they  find  on  investigation  to  be  wrong- 
fully confined,  or  whom  they  find  so  far  sane  as  to  wan-ant  discharge.  But  convicts 
sent  to  an  asylum  from  the  State  Prison  or  House  of  Correction  who  are  found  sane 
before  the  expiration  of  their  sentence  shall  not  be  discharged,  but  the  super^-isors  shall 
order  their  return  to  the  Prison  or  House  of  Correction.  In  no  case  shall  the  siiper- 
visors  order  the  discharge  of  a  patient  without  giving  the  superintendent  of  the  asylum 
an  opportunity  to  be  heard. 

Sec.  2905. — Fine  for  not  FJiseharging  Patient  after  Fecovery. 

If  a  trustee,  superintendent,  employee,  or  other  officer  of  any  asylum  for  the  insane 
woUfully  and  knowingly  neglects  or  refuses  to  discharge  a  patient  after  such  patient 
has  become  sane,  or  after  the  suiDcrvisors  have  ordered  his  discharge,  such  trustee, 
sujterintendent,  employee,  or  other  officer  shall  be  fined  not  more  than  five  hundred 
dollars. 

Sec.  2906. — Physicians'  Certificate  Fequired. 

Xo  person,  except  as  hereinafter  provided,  shall  be  admitted  or  detained  in  an  in- 
sane asylum  as  a  patient  or  inmate  except  upon  the  cei'tificate  of  such  person's  insanity, 
made  by  two  physicians  of  unquestioned  integi'ity  and  skill,  residing  in  the  probate 
district  in  which  such  insane  person  resides,  or,  if  such  insane  person  is  not  a  resident 
of  the  State,  in  the  probate  district  in  which  the  asylum  is  situated ;  or  if  such  insane 
person  is  a  conA-ict  in  the  State  Prison  or  House  of  CoiTection,  such  physicians  may  be 
residents  of  the  probate  district  in  which  such  place  of  confinement  is  situated. 

Sec.  2907.— Certificate— TJlien  to  he  Made. 

Such  certificate  shall  be  made  not  more  than  ten  days  pre'S'ious  to  the  admission  of 
such  insane  person,  and,  with  the  cei'tificate  of  the  judge  of  probate  of  the  district  in 
which  the  physicians  reside  that  such  physicians  are  of  unquestioned  integi'ity  and  skill 
in  their  profession,  shall  be  presented  to  the  proper  officer  at  the  time  such  insane  per- 
son is  presented  for  admission. 

Sec.  2908. — Physicians  to  Certify  upon  E.camination. 

The  certificate  of  the  physicians  shall  be  given  only  after  a  careful  examination  of 
the  supxjosed  insane  person,  made  not  more  than  five  days  preAious  to  the  gi^-iug  of  the 
certificate  ;  and  the  physician  who  signs  the  certificate  without  making  such  pre^-ious 
examination  shall,  if  the  person  is  admitted  to  any  asylum  under  the  certificate,  be  fined 
not  less  than  fif  tv  dollars  and  not  more  than  one  hundred  dollars. 


Code  of  Virginia,  1887. 
Sec.  IQQS.— Annual  Beports. 

The  board  of  each  asylum  shall  annually  before  the  first  day  of  November  report  to 
the  governor,  for  the  information  of  the  general  assembly,  tlie  condition  of  the  asylum. 


ArrEM)ix.  G75 

and  an  aeeonnt  of  all  sums  refeived  anil  disbursed,  with  a  list  of  the  patients  desig- 
nated by  name  or  otherwise  in  the  asylum  during  the  preceding  year,  showing  their 
age  and  sex,  place  of  residence,  and  civil  condition,  deaths,  and  discharges,  and  con- 
dition when  discliarged,  and  any  statistics  and  remarks  as  to  the  management  of  insane 
and  the  subject  of  insanity  wliich  in  their  judgment  nuiy  be  useful. 

Sec.  1669. — Any  justice  who  suspects  any  person  in  his  county  or  corporation  to  be 
a  limatie  shall  issue  his  warrant  ordering  such  person  to  be  brought  before  hira.  He 
and  two  otiier  justices  shall  ini|uire  whether  such  i>erson  be  a  lunatic,  and  for  that 
purpose  summon  his  pliysician  (if  any)  and  any  other  witnesses.   .   .   . 

Sec.  167(1. — If  tlie  justices  decide  that  the  person  is  a  lumitic  and  ought  to  be  eon- 
fined  in  an  asylum — unless  some  person  (to  whom  the  justices,  in  their  discretion,  may 
deliver  such  lunatic)  will  give  bond,  witli  sufficient  security,  to  be  aj>proved  by  them, 
payable  to  the  commonwealth,  with  condition  to  restrain  and  take  proper  care  of  such 
lunatic  until  the  cause  of  his  confinement  shall  cease,  or  the  lunatic  is  delivered  to 
the  sheriff  of  the  county  or  corporation,  to  be  proceeded  with  according  to  law — the 
said  justices  shall  order  him  to  be  removed  to  the  nearest  asylum  on  receipt  of  notice 
of  there  being  room  therein,  and,  if  not,  to  either  of  the  others. 

Sec.  1673. — The  superintendent  of  the  asylum,  when  such  vacancy  exists,  is  author- 
ized, when  practicable,  to  send  a  guard  for  the  lunatic,  or  emjiower  any  person  of 
responsibility  and  character  to  guard  and  conduct  him  to  the  asylum,  and  furnish  the 
person  so  appointed  with  a  certificate  of  his  appointment ;  or,  when  neither  of  such 
ai'rangements  are  practicable,  the  sheriff  shall  conduct  such  lunatic  to  the  asylum.  .  .  . 

Sec.  1674. — Examination  and  Admission  of  Lunatics. 

When  such  patient  arrives  at  the  asylum  the  superintendent  or  his  attendants  shall 
examine  him,  and  if  they  concur  in  opinion  with  the  justices  shall  receive  and  register 
him  as  a  patient. 

Sec.  1688. — Discliarge  of  other  Restored  Lunatics. 

When  any  other  person  confined  in  an  asylum  or  jail  as  a  lunatic  shall  be  restored 
to  sanity,  the  superintendent  or  the  cornet,  as  the  case  may  be,  shall  discharge  him  and 
give  him  a  certificate  thereof. 

Code  of  Washington,  1881. 

Sec.  2251. — Appointmoit  and  Qualifications  of  Superintendent. 

The  superintendent  shall  be  a  skillful  practicing  physician,  and  shall  reside  upon 
the  hospital  grounds ;  he  shall  hold  his  office  for  such  time  as  the  trustees  may  deem 
wise  and  for  the  efficiency  and  economy  of  the  institTition  ;  he  shall  have  entire  control 
of  the  medical,  moral,  and  dietetic  treatment  of  the  patients,  and,  so  far  as  is  not  in- 
consistent with  the  by-laws  and  regulations  of  the  hospital,  of  all  other  internal  govern- 
ment and  economy  of  the  institution ;  and  he  shall,  in  such  manner  and  under  such 
restrictions  and  for  such  terms  of  time  as  the  by-laws  may  prescrilie,  appoint  all  sub- 
ordinate employees,  and  shall  have  entire  direction  of  them  in  their  duties. 

Sec.  2260. — No  Person  Laboring  under  Contagious  Disease  Admitted. 

No  person  laboring  under  any  contagious  or  infectious  disease  shall  be  admitted  in 
said  hosijital  as  a  patient. 

Sec.  2264. —  When  and  How  Patients  may  he  Discharged. 

Any  patient  may  be  discharged  from  the  hospital  when  in  the  judgment  of  the 
superintendent  it  may  be  expedient.  Whenever  a  patient  not  cured  or  any  indigent 
patient  shall  be  ordered  discharged,  the  superintendent  shall  immediately  give  notice 
thereof  to  the  probate  judge  of  the  county  in  which  said  patient  resided ;  and  if  in  the 
judgment  of  the  superintendent  such  patient  so  ordered  to  be  discharged  is  in  fit  con- 
dition to  be  sent  to  his  or  her  coimty  unattended  by  any  jjerson,  the  superintendent 
may  return  the  patient  to  the  county  from  whence  he  or  she  came,  if  indigent,  at  the 
expense  of  said  county ;  but  if  such  patient  so  ordered  to  be  discharged  from  said  hos- 
pital and  care,  without  endangering  tlie  health  of  such  patient,  is  througli  or  by  any 
reason  unfit  to  be  sent  alone  to  the  county  from  which  he  or  she  was  committed  to  said 
hospital,  the  superintendent  shall  so  certify  to  the  probate  judge  of  said  county,  who 


676  APPENDIX. 

shall  immediately  upon  receipt  of  the  notice  issue  Ms  waiTant  to  the  sheriff,  command- 
ing him  to  remove  the  patient  and  retiu'n  him  or  her  to  the  county  from  whence  he  or 
she  came.  If  within  thirty  days  after  the  notice  the  patient  be  not  removed,  the  superin- 
tendent, if  he  think  necessary,  may  return  the  patient  to  the  county  from  which  he 
or  she  came  at  the  expense  of  the  county ;  provided,  that  if  any  such  patient  is  not  in 
a  condition  to  either  go  or  be  removed  to  said  county  he  or  she  may,  for  the  time  being, 
be  retained  in  said  hospital  at  the  expense  of  the  county  from  which  he  or  she  was  so 
committed. 

Sec.  2267. — TJie  Super intendent  shall  Ascertain  History  of  eacli  Patient. 

It  shall  be  the  duty  of  the  superintendent  to  ascertain,  by  diligent  inquiry  and 
correspondence,  the  history  of  each  and  every  patient  admitted  to  the  hospital,  and 
whether  such  patients,  or  their  friends  or  families,  if  there  be  any,  are  able  to  defray 
the  expenses  of  his  or  her  care,  and  report  the  facts  to  the  Board  of  Trustees,  who 
shall  use  efficient  means  for  the  collection  of  all  sums  due  the  institution  from  those 
who  are  able  to  pay  for  such  care. 

Sec.  2273. — Corresjyondence  of  Patients  Free  from  Censorsldp. 

There  shall  be  no  censorship  exercised  over  the  correspondence  of  inmates  of  insane 
asylums,  except  as  to  the  letters  to  them  directed ;  but  their  other  post-office  rights 
shall  be  as  free  and  unrestrained  as  are  those  of  any  other  resident  or  citizen  of  this^ 
Territory,  and  be  under  the  protection  of  the  same  postal  laws  ;  and  every  inmate  shall 
be  allowed  to  write  one  letter  per  week  to  any  person  he  or  she  may  choose.  And  it 
is  hereby  made  the  duty  of  the  superintendent  to  furnish  each  and  every  inmate  of 
each  and  every  insane  asylum,  both  pjublic  and  private,  in  the  Territory  of  Washing- 
ton, with  suitable  material  for  writing,  inclosing,  sealing,  stamping,  and  mailing  letters 
sufficient  for  wi'itiug  of  one  f oui'-paged  letter  a  week,  provided  they  request  the  same, 
unless  they  are  otherwise  furnished  with  it;  and  all  these  letters  shall  be  dropped  by 
the  Tvriters  themselves,  accompanied  by  an  attendant  when  necessary,  into  a  post- 
office  box,  provided  by  the  Territory  at  the  institution,  in  some  place  easily  accessible 
to  all  the  patients  ;  and  the  contents  of  these  boxes  shall  be  collected  at  least  as  often 
as  once  a  week  by  an  authorized  post-office  agent.  And  it  is  hereby  made  the  duty  of 
the  supeiintendent  of  every  insane  asylum  in  the  Ten-itory  of  Washington,  both  public 
and  private,  to  deliver  or  cause  to  be  delivered  to  said  person  any  letter  or  wi-iting  to- 
him  or  her  directed,  provided  the  physician  in  charge  does  not  consider  the  contents 
of  such  letter  dangerous  to  the  mental  condition  of  the  patient. 

Sec.  2282. — Upon  Delivery  of  Patient,  Superintendent  must  Give  Certificate,  Stating 
Name  of  Patient  and  County. 

Whenever  any  patient  is  delivered  at  the  asylum  under  the  i)rovisions  of  this  act, 
the  superintendent  of  the  asylum  shall  give  to  the  sheriff  or  guard  delivering  such 
patient,  a  certificate  stating  the  name  of  the  patient,  from  what  county  admitted,  and 
the  court  that  committed  the  same. 

Laws  of  Washington,  1883. 

Sec.  1632. — The  Probate  Court  of  any  county  in  this  Territory,  or  the  judge  thereof, 
upon  application  of  any  jjerson  under  oath,  setting  forth  that  any  person  by  reason  of 
insanity  is  unsafe  to  be  at  large  or  is  suffering  under  mental  derangement,  shall  cause 
such  jjerson  to  be  brought  before  said  court  or  judge,  at  such  time  and  place  as  the 
court  or  judge  may  direct,  and  shall  cause  to  appear  at  said  time  and  place  one  or  more 
respectable  physicians,  who  shall  imder  oath,  in  writing,  give  their  opinion  of  the  case, 
which  opinions  shall  be  carefully  preserved  and  filed  with  other  papers  in  the  case  ;  and 
if  the  said  physician  or  physicians  shall  certify  to  the  insanity  or  idiocy  of  said  person, 
and  it  appear  to  the  satisfaction  of  the  coiirt  or  jridge  that  such  is  the  fact,  said  court 
or  judge  shall  cause  such  insane  or  idiotic  person  to  be  taken  to  and  placed  in  the 
Hospital  for  the  Insane  of  Washington  Territory ;  provided  that  such  person,  or  any 
person  in  his  behalf,  may  demand  a  jury  to  decide  upon  the  question  of  his  insanity, 
and  the  court  or  judge  shall  discharge  such  person  if  the  verdict  of  the  jury  is  that  he 
is  not  insane  ;  provided,  also,  that  when  the  relations  or  friends  desire  to  take  charge 
of  such  insane  or  idiotic  person  the  court  or  judge  may  so  order,  if  they  shall  give  bonds, 
to  be  approved  by  said  judge,  conditioned  that  such  insane  or  idiotic  person  shall  be 
well  and  securely  kept. 


A  I' r LSD IX.  C77 


Amended  Code  of  West  Virginia,  1884. 

Chapter  58,  Section  7. —  West  Vir<ihil(i  JlospiinI  for  iJir  hisauc. 

A  superiiiloiuk'nt  and  as  many  assisUiiits  as  may  lie  iiecessavy,  wlio  sliall  he 
physicians,  and  other  officers,  shall  be  a)>poiiitcd  Ity  the  board,  and  shall  receive 
such  coniiiensation  as  tlie  board  may  prescribe.  The  T)oard  may  also  ai»point  an 
executive  committee,  and  may  authorize  the  su])erintendent  to  eiuj)loy  as  jnany  nurses 
and  attendants  as  may  be  necessary,  ami  also  discharge  them,  or  any  of  them,  and  em- 
])loy  otliers,  ))ut  the  board  shall  fix  their  compensation.  Any  one  or  more  of  the 
directors,  together  with  the  superintendent,  shall  constitute  an  Examining  Board, 
and  may  examine  i)ersons  brought  to  thc^  asylum  as  lunatics,  and  order  those  found  to 
be  such  to  be  received. 

Sec.  11  (Acts  of  1882,  p.  1.33).— Any  justice  who  sluiU  suspect  any  person  in  his 
county  to  be  a  lunatic  shall  issue  his  warrant,  ordering  such  person  to  be  brought  before 
him.  He  shall  inquire  whether  sucli  person  be  a  lunatic,  and  for  that  purpose  summon 
a  physician  aiul  other  witnesses.  In  additioji  to  any  other  questions  he  may  propound 
as  many  of  the  following  as  may  be  applicable  to  the  case  :  1.  AVhat  is  the  patient's 
age,  and  where  born?  2.  Is  he  married;  if  so,  how  many  children  has  he?  3.  "Wliat 
are  his  liabits  and  occupation?  4.  How  long  since  indications  of  insanity  ap- 
peared? 5.  What  were  they?  6.  Does  the  disease  appear  to  increase?  7.  Are  there 
l)eriodical  exacerbations  ;  any  lucid  intervals,  and  of  what  duration?  8.  Is  his  derange- 
ment evinced  on  one  or  on  several  subjects  ;  what  are  they?  9.  What  is  the  supposed 
cause  of  his  disease  ?  10.  What  change  is  there  in  his  bodily  condition  since  the  attack? 
11.  Has  Ihei'e  been  a  former  attack;  when,  and  of  what  duration?  12.  Has  he  sIio^ati 
any  disi)osition  to  commit  violence  to  himself  or  others?  13.  Whether  any,  and  what 
restraint  has  been  imposed  on  him?  14.  If  any,  what  connections  of  his  have  been 
insane.  Were  his  parents  or  grandparents  blood  relations  ;  if  so,  in  what  degree?  15. 
Has  he  any  bodily  disease  from  suppression  of  evacuations,  emiptions,  sores,  injuries, 
or  the  like,  and  wliat  is  its  history?  What  ciu-ative  means  have  been  pursued  and  their 
effect,  and  especially  if  depleting  remedies,  and  to  what  extent,  have  been  used  ? 

Sec.  12. — If  the  said  justice  decide  that  the  person  is  a  lunatic  and  ought  to  be 
confined  in  the  hospital,  and  ascertain  that  he  is  a  citizen  of  this  State,  then — unless 
some  person  to  whom  the  justice,  in  his  discretion,  may  deliver  such  hmatic,  will  give 
boiul,  with  sufficient  security,  to  be  approved  by  said  justice,  payable  to  the  State,  with 
condition  to  restrain  and  take  piroper  care  of  such  lunatic  until  the  cause  of  confinement 
shall  cease,  or  the  lunatic  is  delivered  to  the  Sheriff  of  the  county,  to  be  proceeded 
with  accoi'ding  to  law — the  said  justice  shall  order  him  to  be  removed  to  the  hospital 
and  received,  if  there  be  room  therein. 

Sec.  23. — JJlioi  PcrsoHs  dkuj  he  Discharged  from  HospiiaJ. 

Except  in  the  case  of  a  person  charged  with  crime  and  subject  to  be  tried  therefor, 
or  convicted  of  crime  and  subject  to  be  punished  therefor,  when  in  a  condition  to  be 
so  tried  or  punished,  the  board  of  the  hospital,  or  the  circuit  coiu't  of  any  coimty.  may 
deliver  any  lunatic  confined  in  the  hospital  or  in  the  jail  of  such  county  to  any  friend 
who  will  give  bond  with  security,  Avith  the  condition  mentioned  in  the  twelfth  section 
of  this  chapter  ;  and  where  a  lunatic,  except  as  aforesaid,  is  deemed  by  the  superintend- 
ent of  the  hospital  both  harmless  and  incurable,  the  board  may  deliver  him  without 
such  bond  to  any  friend  who  is  Avilling  and,  in  the  opinion  of  the  board,  able  to  take 
care  of  liim. 

Sec.  50. — (Iciicral  Prorisiinis. 

If  any  director  of  the  hosi)ital.  justice,  clerk  of  a  court,  or  other  officers  shall  fail 
to  perform  any  duty  required  of  him  in  the  chajiter,  or  shall  offend  against  any  prohibi- 
tion contained  herein,  he  shall  forfeit  not  less  than  fifty  nor  more  than  one  hundred 
dollars. 

Sec.  51 . — The  word  "  lunatic, "  whenever  it  occurs  in  this  chapter,  shall  be  consti'ued 
to  include  every  insane  person  who  is  not  an  idiot. 


678  APPENDIX. 

Revised  Statutes  of  Wisconsin,  1879-1883, 
Chapter  32,  Section  588. — Duties  of  the  Superintendent. 

The  siiperinteudent  of  each  hospital  shall,  before  entering  upon  the  duties  of  his 
office,  take  and  subscribe  an  oath  faithfully  and  diligently  to  discharge  the  duties  re- 
quired of  liini  by  law  and  the  by-laws  of  the  Board  of  Trustees.  He  shall  be  chief 
executive  officer  of  the  hospital,  and  shall  devote  all  his  time  and.  attention  to  his 
duties  ;  he  shall  exercise  entire  control  over  all  the  subordinate  officers  ;  he  shall  employ 
all  employees  and  assistants  necessarily  connected  with  the  institution  below  the  grade 
designated  in  the  by-laws  as  officers,  and  may  discharge  any  officer,  assistant,  or  em- 
ployee at  will,  being  responsible  to  the  Board  of  Trustees  for  the  proper  exercise  of 
that  dutj^  in  regard  to  officers.  The  sujjerintendent  shall  not  be  compelled  to  obey  the 
subpoena  of  any  coiu't  in  any  case,  civil  or  criminal,  if  he  shall  tile  with  the  magistrate 
or  clerk  his  affidavit  that  to  obey  the  same  would  be  seriously  deti'imental  and  hazard- 
ous to  the  welfare  of  the  hospital  under  his  charge,  except  when  an  accusation  of 
murder  is  to  be  tried ;  nor  in  such  case,  unless  the  judge  shall  make  a  special  order 
therefor,  and  the  subpoena,  with  a  memorandum  thereof  indorsed  thereon,  be  served 
one  week  before  the  time  when  he  shall  be  required  to  appear ;  jiruvided,  however, 
that  no  person  shall  be  entitled,  in  any  case,  to  make  and  file  such  affidavit,  exempting 
him  from  subpoenas  as  aforesaid,  who  shall  upon  tender  of  the  usual  fees  of  witnesses, 
in  courts  of  record,  refuse  to  be  present  and  to  give  his  deposition  at  his  office  or  usual 
place  of  business,  or,  instead  thereof,  at  his  house  or  usual  place  of  abode ;  provided 
f  ui'ther,  that  any  person  so  present  and  giving  his  deposition  at  his  office  or  usual  place 
of  biisiness,  or,  instead  thereof,  at  his  hoiise  or  usual  jjlace  of  abode,  who  shall  be  de- 
tained four  hoiu's  from  the  time  fixed  for  tlie  taking  of  such  deposition,  or  from  the  time 
to  which  the  taking  of  the  same  may  have  been  adjoiirned,  may  make  affidavit  that 
further  detention  Avould  be  seriouslj^  detrimental  or  hazardoiis  to  the  welfare  of  the 
person  or  business  in  or  under  his  charge ;  and  such  affidavit  having  been  made,  a 
justice  of  the  peace,  court  commissaries,  notary  public,  or  other  authorized  officer  be- 
fore whom  such  deposition  is  given,  shall  thereupon  adjourn  further  proceedings  thereon 
to  a  future  day. 

Sec.  593. — Proceedings  to  Determine  Insanity — Examination  hy  Physicians. 

Whenever  any  resident  of  this  State,  or  any  person  fi-om  therein  whose  residence 
cannot  be  ascertained,  shall  be  or  be  supposed  to  be  insane,  application  maj^  be  made 
in  his  behalf  by  any  respectable  citizen  to  the  judge  of  the  County  Court,  judge  of  the 
Circuit  Court,  or  any  judge  of  a  court  of  record  in  and  for  the  county  in  which  he  resides, 
or,  in  case  his  residence  is  unknown,  the  county  in  which  he  is  found,  for  a  judicial 
inquiry  as  to  his  mental  condition,  and  for  an  order  of  commitment  to  some  hospital 
or  asylum  for  insane.  The  application  shall  be  in  writing  and  shall  specify  whether 
or  not  a  trial  by  jury  is  desired  by  apjjlicant.  On  receipt  of  said  petition  the  judge 
to  whom  it  is  adch'essed  shall  appoint  two  disinterested  physicians,  of  good  repute  for 
medical  skill  and  moral  integrity,  to  visit  and  examine  the  person  alleged  to  be  insane  ; 
and  such  physicians  shall  proceed  without  unnecessary  delay  to  the  residence  of  the 
person  supposed  to  be  insane,  and  shall  by  personal  examination  and  inquiries  satisfy 
themselves  fully  as  to  his  condition  and  report  the  result  of  their  examination  to  the 
judge.  ... 

.  .  .  Upon  the  receipt  of  the  report  of  the  examining  physicians  the  judge 
may,  if  no  demand  has  been  made  for  a  jury,  make  and  enter  his  order  of  commitment 
to  the  hospital  or  asylum  of  the  district  to  which  the  county  belongs,  or,  if  not  fully 
satisfied,  lie  may  make  such  additional  investigation  of  the  case  as  may  seem  to  him  to 
be  necessary  and  proper ;  and  at  any  stage  of  the  proceedings,  and  before  the  actual 
confinement  of  the  person  alleged  to  be  insane,  lie,  or  any  relative  or  fi-iend  acting  in 
liis  behalf,  shall  have  the  right  to  demand  that  the  question  of  sanity  be  tried  by  a 
jury,  and  when  such  demand  is  made  the  judge  shall  forthwith  enter  an  order  for  a 
jury  trial. 

In  ease  a  trial  by  jury  is  demanded,  the  forms  of  procedure  shall  be  the  same  as  in 
trials  by  jury  in  justices'  courts,  and  the  trial  shall  be  in  the  presence  of  the  person  sup- 
posed to  be  insane,  and  his  counsel  and  immediate  friends  and  the  medical  wit- 
nesses. .  .  . 

County  Jiid(/e  may  Order  Insane  Persons  Confined. 

On  receipt  by  the  county  judge  of  the  petition  provided  for  by  section  1  of  chapter 
266  of  the  General  Laws  of  1880,  such  judge  may,  if  in  his  opinion  the  public  safety 


Al'l'KXDIX.  G79 

requires  it,  deliver  to  the  sheriff  of  Lis  county  an  order  iu  writing  requiring  him  forth- 
witli  to  take  and  eonfine  such  insane  or  supposed  insane  person  in  some  jdace  to  be 
specified,  until  further  order  of  the  judge  ;  and  after  the  receipt  by  siicli  judge  of  the 
report  of  the  exiimining  physicians  provided  for  in  said  chapter,  sucii  judge  may,  in 
his  discretion,  deliver  to  sucli  officer  such  order  in  writing  reijuiring  him  forthwith  to 
take  such  person  into  custody  and  keep  him  in  some  place  to  be  specified,  until  tlie 
further  order  of  sucli  judge.  The  examining  physicians  provided  for  by  said  section 
1  of  said  chapter  26G,  in  addition  to  the  report  required  to  be  made  by  them  by  said 
section,  shall  state  as  follows  :  Has  the  patient  any  infectious  disease  ?  In  yoiu*  opinion 
is  he  insane? 

...  If  any  relative  or  friend — being  of  a  legal  age  and  competent  to  perfoiTa 
the  duties — of  any  person  committed  to  any  hospital  for  the  insane  shall  request  the 
warrant  for  such  commitment  may  be  delivered  to  and  executed  by  him,  he  shall  be 
l)aid  his  necessary  expenses,  not  exceeding  the  fees  and  expenses  now  allowed  to 
■sheriffs  according  to  law  ;  otherwise  it  shall  be  delivered  to  the  sheriff,  who,  taking  such 
assistants  as  the  courts  issuing  such  warrants  may  deem  necessary,  shall  receive  such 
insane  person  and  convey  him  to  the  hospital. 


Revised  Statutes  op  "Wyoming,  1887. 

Sec.  2287. — Ai)pJlcatio)i  for  Inquisition. 

If  information  in  writing  be  given  to  the  probate  judge  that  any  person  in  the 
-eonnty  is  an  idiot,  lunatic,  or  person  of  unsound  mind,  or  an  habitual  drunkard,  or 
ineajiable  of  managing,  and  praying  that  an  inquiry  therein  to  be  had,  the  court,  if 
satisfied  that  there  be  good  cause  for  the  exercise  of  its  jm-isdiction,  shall  cause  the 
facts  to  be  inquired  into  by  a  jury. 

Sec.  2288. — Court  may  Act  in  Vacation. 

Such  information  may  also  be  given  in  the  vacation  of  said  coiu't,  to  the  judge 
therefor,  in  which  event  he  shall  call  a  special  term  of  the  court  for  the  purj)ose  of 
holding  an  inquiry  whether  the  ijerson  mentioned  in  such  information  be  of  unsound 
mind  or  an  habitual  drunkard,  or  not. 

Sec.  2289. — Person  may  he  Brought  into  Court. 

In  proceeding  under  this  chapter  the  Probate  Court  may,  in  its  discretion,  cause 
the  person  alleged  to  be  of  unsound  mind  or  habitual  drunkard  to  be  brought  before 
the  court. 

Sec.  2290. — "Whenever  any  judge  of  the  Probate  Court,  justice  of  the  peace,  sheriff, 
coroner,  or  constable,  shall  discover  any  person  resident  of  his  county  to  be  of  imsound 
mind  or  an  habitual  dninkard,  as  in  the  first  section  of  this  chapter  mentioned,  it  shall 
be  his  duty  to  make  application  to  the  Probate  Court  for  the  exercise  of  its  jurisdiction, 
and  thereupon  the  like  proceedings  shall  be  had  as  in  the  case  of  information  by  un- 
official persons. 

1888. 

Chapter  85.  Section  1. — That  section  No.  3765  of  the  Revised  Statutes  of  "Wyo- 
ming be  amended  and  revised  so  as  to  read  as  follows  :  Section  3765. — After  the  building 
herein  provided  for  shall  have  been  completed  and  accepted  by  the  Board  of  Commis- 
sioners the  board  shall  serve  notice  in  writing  uj)on  the  Boards  of  County  Conunis- 
sioners  of  all  the  different  counties  in  this  Territory,  which  notice  shall  state  that  the 
asylum  for  insane  at  Evanston  is  now  completed  and  ready  for  the  reception  and  care 
of  insane  persons.  Each  Board  of  County  Commissioners  shall,  after  the  receipt  of 
such  notice,  cause  all  persons  adjudged  to  be  insane,  and  whose  care  shall  have  been 
thrown  upon  the  coiinty,  to  be  sent  as  patients  to  the  Insane  Asylum  at  Evanston, 
there  to  be  kept  and  cared  for  at  the  expense  of  said  coimty.  And  all  insane  persons 
having  been  sent  to  asylums  outside  of  this  Territory  shall,  upon  the  completion  of 
said  asyhnu  at  Evanston,  and  notice  to  the  Board  of  County  Commissioners  as  herein- 
before provided,  be  returned  as  soon  as  practicable,  under  an  order  of  the  respective 
Boards  of  County  Commissioners,  to  this  county,  to  be  kept  and  cared  for  at  the  insane 
asylum  at  Evanston. 


680  APPENDIX. 


Sec.  3764  (1887). — Siqjerintendent  of  Asylums — Qualifications  and  Duties. 

The  Board  of  Commissioners  shall  elect  one  resident  physician,  who  shall  be  the 
general  supeiintendent  of  the  insane  asylum  herein  pro^dded  for,  subject  at  all  times 
to  the  order  and  duties  of  said  board,  which  shall  have  power  at  any  time,  whenever 
in  their  Judgment  it  shall  be  deemed  i^roper  and  for  the  best  interests  of  the  Tenitory, 
to  discharge  and  remove  such  superintendent.  The  superintendent  so  elected  shall 
reside  at  the  asylum,  be  a  graduate  in  medicine,  and  receive  a  salary  of  eighteen 
hundred  dollars  per  year,  payable  in  advance  in  equal  installments.  He  shall  cause 
to  be  kept  a  fair  and  full  account  of  all  his  doings  and  the  actual  business  and  opera- 
tions of  the  institution,  and  submit  a  monthly  report  to  the  Board  of  Commissioners. 
The  supeiintendent  shall  employ  all  necessary  help  needed  at  the  asylum,  subject  to 
the  approval  of  the  Board  of  Commissioners. 

Sec.  3766. — Paying  patients,  whose  friends  offer  and  will  pay,  or  who  have  property 
to  pay  their  expenses,  shall  be  admitted  to  the  insane  asylum,  according  to  the  terms 
directed  by  the  Board  of  Commissioners  thereof ;  but  the  insane  poor  shall  in  all  re- 
spects receive  the  same  medical  care  and  treatment,  and  be  given  as  wholesome  food^ 
as  is  given  to  paying  patients. 


iisrDE:^:. 


PAGE 

Aberration,  mental,  influence  of,  upon  capacity  of  individual n.  112 

Abortion,  clinical  evidences  of :  changes  in  maternal  organism  dm-ing  preg- 
nancy, condition  of  utero-vaginal  tract,  genital  discharges II.  472 

stains  upon  bedding  or  clothing II.  475 

criminally  induced IE.  468 

(a)  medicinal  measures :  ergot,  tansy,  cotton-root,  sa^"in,  rue,  yew,  saf- 
fron, peunyroj'al,  cathartics,  apiol.  chloride  of  iron II.     469,  470 

(6)  mechanical  measures  :  blows,  jolts,  douches,  tents,  etc .11.  470 

defined H.  467 

dii"eet  interference  to  produce  :  detachment  of  ovum,  perforation  of  fetus, 

galvanic  ciu-rent U.  471 

evidences  of  criminal II.  477 

that  confiuement  has  occurred 11.  478 

feigned 11.  478 

infanticide II.  479 

legitimately  induced 11.  468 

non-induced  or  spontaneous II.  467 

post-mortem  signs  of 11.  475 

relations  of  physicians,  etc.,  to  the  patients  in  eases  of I.  638 

size  of  uterus  and  development  of  fetus 11.  477 

stage  of  gestation  when  abortion  took  place II.  476 

Abscess  of  testicle II.  628 

Abuse,  sexual,  of  children ;  manustupration II.  545 

Accident,  death  by  drowning I.  128 

hanging  or  strangulation I.  120 

suffocation I.  Ill 

disease  the  result  of,  in  relation  to  insurance I.  5S5 

in  relation  to  insurance I.  583 

Accident  Cases,  damages  for  loss  of  income II.  383 

defined II.  377 

inviolability  of  the  person II.  378 

negligence  of  injured  party 11.  380 

physical  examination  before  trial II.  377 

questions  for  medical  expert II.  379 

recovery  of  cost  of  medical  attention 11.  384 

ultimate  and  direct  results  of  injiu-ies II.  380 

Accident  Insurance  (see  Insurance) I.     493.  583 

Acetic  Acid I.  490 

081 


682  INDEX. 

PAGE 

Acids,  boracie,  'borie,  eliromie,  chromic  anhydride,  potassic  dichromate I.  332 

hydrochloric,  muriatic I.  329- 

mineral » =  1.  326 

nitric,  aqua  fortis = I.  330 

sulphiuic,  oil  of  vitriol I.  326 

AcoxiTE,  aconitin,  aconitine,  aconitia,  aconitina I.  421 

ACQUETTA    DI   PeRUGIA I.  496 

Action,  reflex II.  21 

Acute  Alcoholism II.  95 

Acute  Dementia II.  109 

Adipocere I.  104 

Adolescent  Insanity II.  90 

Affections  of  Memory II.  46 

Age,  determination  of  the-  indications  of I.  194 

as  determined  hy  skeleton I.  56 

Age  of  consent I.  651 ;  II.     517,  525 

Agoraphobia  . » , II.  45 

Agraphia II.  268 

Alalia II.  267 

Alcohol,  insanity  due  to II.  205- 

Alcoholic  general  i^aresis II.  97 

insanity II.  95- 

hallucinations  in II.  96 

Alcoholism II.     59,  123,  205 

habitual  drunkards II.  152' 

Alealoidal  and  other  Organic  Poisons  (see  Poisons) I.  415' 

Alkaloids,  animal  (see  Poisons) I.  475 

mydi'iatic I.  427 

Ammonia I.  324 

Amnesic  Aphasia II.  267 

Amputations  (see  Sm-gery) II.  621 

Anesthesia,  cutaneous,  in  traumatic  neuroses II.  339 

feigned II.  403 

sexualis II.  557 

Anesthetics,  administration  of II.  598. 

never  without  assistant II.  594 

to  pregnant  women II.  600 

with  witnesses,  with  female  patients II.  595 

bromide  of  ethyl,  hj^drobromic  ether II.  603 

cause  of  death II.  595 

chloroform,  fatal  narcosis II.  596 

idiosyncrasy II.  598 

dangerous  narcosis,  treatment  of II.  599 

death  under II.  594 

by  suffocation  from I.  113 

indirect  causes  of II.  596 

effect  of,  upon  kidnej'S II.  597 

ether,  objections  to II.  600 

failure  of,  to  produce  results II.  602 

nitrous  oxide II.  603 

statistics,  reports,  and  cases <. II.  601 


INDEX.  G83 

PAon 

Analysis,  spectrum,  of  blood-stains I.  142 

Anchylosis II.  621 

Aneurism,  case  of  mistaken II.  60(> 

diagnosis  of II.  605 

sm-gical  malpractice  in  treating II.  60.5 

Anoulah  Gyrus  of  the  brain II.  27 

Antimony,  antimony  chloride,  antimoniureted  hydrogen,  butter  of  antimony.  I.  341 

Aphasia,  agraphia II.  268 

amnesic  and  ataxic II.  267 

apraxia II.  2Q[) 

bulbar  and  pseudobulbar  affections  of  speech II.  281 

cases  of :  BcA'en,  Fillmore  will II.  262 

Parish  will II.  261 

cerebral  centers  in  meclianism  of  speech II.  269 

disorders  of  pantomime  in II.  287 

cases II.     289-296 

dyslexia II.  272 

forms  of  speech  disorders  produced  by  lesions II.  270 

history  and  literature  of II.  25i> 

interdiction  of  aphasics II.  261 

measure  of  capacity II.  266 

medico-legal  aspects  of II.  259 

questions  in  connection  with II.  263 

mental  disturbance  in II.  261 

status  of  motor  aphasics II.  279 

of  sensory  aphasics II.  27;> 

in  verbal  amnesia II.  277 

in  word-blindness II.  275 

in  word-deafness II.  274 

motor  or  emissive II.  267 

paraphasias  or  conduction  aphasias II.  268 

psychical  blindness  and  deafness II.  268 

sensory  or  receptive II.  267 

simulated,  mimetic,  etc.,  affections  of  speech II.  285 

speech  disturbances,  associated  with  insanitj'  and  epilepsy II.     283,  284 

in  (bearing  on  insanity) II.  47 

testamentary  capacity  in II.  265 

total II.  268 

verbal  amnesia II.  268 

Aphemia II.  267 

Apperception  of  the  mind II.  19 

Apraxia II.  269 

Aqua  Tofpana I.     350,  490 

Arsenic,  arsenic  acid,  arsenates,  arsine,  arseniureted  hydrogen,  siilphides. . .  I.  380 

arsenious  acid,  arsenious  oxide,  white  arsenic I.  356 

eating,  Maybrick  case  .  ■ I.  369 

metallic I.  355 

Asemasia II.  267 

Aseptic  and  antiseptic  sm-gery II.  590 

Asphyxia,  djTiamical I.  113 

in  di'o wiling I.  120 


684  INDEX. 

PAGE 

Assaults,  criminal  (see  Post-mortem  Examinations) I.  33 

indecent,  upon  children I.     649  ;  II.  525 

Association,  benefit  (see  Insm-ance) I.  493 

Asylum  Physician,  a  mere  custodian II.  147 

Ataxia,  ataxic  aphasia II.  267 

feigned ._ II.  402 

Ataxiagram II.  315 

Atheroma  of  the  scalp 11.  609 

Atropine,  atroj)in,  atropia I.  424 

Autopsy  (see  Post-mortem  Examinations) I.     25,  57 

government  regulation  of I.  57 

in  death  from  electric  shock II.  369 

proper  time  for I.  36 

Baby-farming I-  137 

Belladonna I-  424 

Benefit  Association  (see  Insurance) I.  493 

Bibliography,  blood-stains I.  186 

effects  of  electric  currents II-  376 

insanity  and  crime II-  214 

insanity  in  its  medico-legal  relations II.  160 

traumatic  neuroses II.  352 

Birth,  child,  number  a  woman  may  or  should  have = 11.  461 

substitution  and  suppression  of II.  459 

viability  of , II.  450 

delivery,  C^esarean  section II-     456,  459 

duties  of  physicians  in II-     456,  466 

premature  labor,  induction  of II-  460 

symphyseotomy II-  459 

lactation H.  458 

legal  obligations  of  physician  in  recording II-  417 

French  Civil  Code II-  418 

legal  procedure  against  physicians II.  465 

obstetrics H-     459,  463 

pregnancy,  artificial  insemination II.  439 

conception,   marriage   and   conception,   interference  to   pre- 
vent conception II-  437 

duration  of  gestation,  its  bearing  on  legitimacy II-     450,  453 

extra-uterine = II-  440 

laws  of  different  coimtries  regarding II.  453 

multiple II-  446 

past  or  present  condition  of II-  462 

signs  of II-  441 

Hegar's II.  442 

kiestein,  ballottement II.  443 

simulation  of H-  444 

sterility,  relative  and  absolute II-  439 

superf  elation H-  446 

puerperal  fever,  local  inj;iries II.  457 

state II-  456 

Blindness,  feigned II-  406 

Blood,  ai-terial,  venous,  menstrual I-  l''^9 


INDEX.  G85 

pa(;k 

Blood,  chemical  composition  of I.  140 

corpuscles I.     150,  171,  173 

distinctions  between  liunian  and  other I.  172 

fluidity  of,  after  death I.  99 

gi'avitation  of,  in  capillaries  after  death I.  96 

tests  for I.     157-162 

transfusion  of II.  586 

Blood-stains  (see  Wounds  and  Post-moi'tem  Examinations) I.  139 

action  of  alcohol,  ether,  chloroform,  etc I.  150 

ammonia,  alkalies,  bleaching  agents,  effect  of  heat I.  149 

chemical  agents  upon  blood I.  149 

tincture  of  galls  and  of  guaiacnm I.  150 

water I.  149 

age  of I.  179 

bibliography  of I.  186 

blood,  chemical  and  physical  properties  of I.  139 

chemical  composition  of I.  140 

color  of I.  139 

distinction  between  human  and  other I.  172 

Alley  ease I.  179 

dried I.  141 

menstrual,  arterial,  and  venous I.  179 

blood-coloring  matter I.  140 

blood-corpuscles,  measurements  of I.     150,  171,  173 

crystalline  bodies  obtained  from I.  147 

hpematin I.  141 

ha?moglobin I.  140 

crystals I.  148 

spectroscopic  appearances  of I.  144 

Stokes'  baud I.  147 

optical  properties  of I.  142 

red  corpuscles,  comparative  study  of I.  150 

number  of I.  151 

epithelium  from  vaginfe I.  180 

illustrative  cases  of I.  180 

microscopical  examination  of I.     167,  1 69 

attempted  distinction  between  blood  of  man  and  cow I.  ISO 

man  and  duck ;  man  and  sheep  I.  181 

blood-clots I.  168 

cases  :  Commonwealth  (w.  Piper,  State  of  Connecticut  vs.  Hayden I.  169 

illustrative  eases I.  170 

materials  found  associated  with  blood I.  171 

spores  of  porphjTidium I.  170 

microspectroscope T.  143 

examination  by I.  144 

seminal  stains I.  184 

spermatozoa I.  185 

trichimouas  vagina^ I.  185 

spectrum  analysis  of I.  142 

testing  of  suspected  stains I.  152 

appearauee  of  drops,  etc.,  and  of  stains I.  155 


686  INDEX. 

PAGE 

Blood-stains,  corrosions  upon  metals,  and  drops  and  clots  upon  them I.  156 

dye-woods  and  tanning  materials,  grease  or  tar,  red  paint,  vegetable 

stains I.  157 

preliminary  examination I.  152 

tests,  chemical % I.  158 

guaiacum I.     158,  159 

hsBmin I.     158,  162 

histological I.  158 

microspectroseope I.  164 

spectroscope I.  158 

substances  producing  blue  color I.  161 

Bkain,  anatomy  of II.  22 

arrested  development  of,  idiocy II.  188 

arterial  supply  to  base  of • II.  26 

centers  :  psychic,  sensory,  motor,  geniea;late,  aphasic ;  agraphic,  aphasic, 
of  lower  extremity,  of  superior  extremity ;  motor,  of  face,  of  word- 
blindness,  of  hemianopsia,  of  word-deafness,  of  uneiate  gyrus II.  24 

cortical  centers,  angular  gyrus II.  27 

fibers,  association  of II.  22 

course  of  pyramidal II.  23- 

mind,  its  dependence  on  activity  of  (see  Mind) II.  1& 

tolerance  of,  to  injury II.     19,  21 

New  England  blasting  case II.  21 

weight  of,  Broca  and  Gratiolet II.  20 

Bright's  Disease,  as  a  cause  of  insanity II.  60 

as  affecting  insurance I.  537 

Bromide  op  Ethyl,  hydrobromic  ether  (see  Anaesthetics) II.  603 

Bromine,  potassium  bromide I.  334 

Brucine,  brucin,  brucia I.  460 

Bulbar  and  jiseudobulbar  affections  of  speech II.  281 

Bullets  (see  Wounds) I.  726 

Burns  (see  Wounds) I.  288 

CESAREAN  Section II.     456,  459,  460 

Calculus,  vesical II.  628 

Calomei^  mercuric  and  mercurous  chloride,  mercuric  bichloride I.  400 

Camphor I.  472 

Cancroin  I.  492 

Cannabis  Indica II.  33 

Cantharides,  Spanish  fly I.  472 

Capacity,  mental II.  114 

testamentary II.  115' 

Carbolic  Acid I.  469' 

Carbonic  Acid,  death  from  suffocation  by I.  US' 

Cases  : 

alcoholism  (Von  Krafft-Ebing's) II.  206 

Alley  (Leavitt),  blood-stains I.  179 

aphasic  affections II.     289-296 

Ayer  vs.  Eussell,  insanity  and  false  imprisonment II.  147 

Baker  vs.  Baker,  insanity  and  divorce II.  142 

Banker  vs.  Banker,  insanity  and  divorce II.  133 

Banks  vs.  Goodfellow,  insanity  and  will II.     118,  170 


INDEX.  687 

PAGE 

Cases : 

Bell  vs.  Bennett,  insanity  and  annulment  of  marriage II.     1 36 

Belliiigham,  right  and  wrong  test II.     228 

beneficiary  on  life-insurance  policy I.     507,  508 

Beven,  contract  with  aphasic II.     262 

Billings,  gunshot  wounds I.     263 

Blakely,  insanity  and  will II.     12I 

Bliss  vs.  C.  &  P.  R.  R.  R.,  habitual  drunkard II.     158 

Blodgett,  habitual  di-unkard II.     153 

Boyd  vs.  Eby,  lucid  interval  and  insanity II.     113 

Brady  vs.  jMcBride,  insanity  and  will II.     117 

brain,  tolerance  to  injury,  New  England  blasting  ease II.       21 

Briggs,  gunshot  woiinds I.     262 

Brown  vs.  Howe,  insanity  and  torts II.     143 

Brown  vs.  Riggin,  insanity  and  will II.     122 

Bi-uin,  wounds,  self-inflicted I.     281 

Budge,  Mrs.,  knife-wounds I.     249,  259,  273,  277 

Carter  vs.  Beckwith,  claim  against  lunatic II.     142 

Cherbonnier  vs.  Evitts,  insanity  and  will II.     122 

Colvocoresses,  Captain,  suicide I.     282 

Commonwealth  vs.  Piper,  blood-stains I.     169 

Cramer,  Jennie,  poisoning,  arsenic I.     381 

death  under  anassthetie II.     594 

delusions,  insane II.     235-241 

of  rape II.     211 

Dickie,  commissioner  in  lunacy II.     139 

Dickinson  vs.  Barber,  degree  of  insanity II.     144 

Dills  vs.  State  of  Indiana,  compulsory  expert  testimony II.     150 

Ducker  vs.  Whitson,  contract  with  lunatic II.     130 

Eddy,  insanity  and  will II.     117 

electric  currents,  burning '. II.     371 

damages  for  iujiu-y  or  death  and  loss  of  income ...  .II.      378-383 

death  from II.     368,  369 

effects  of II.      373-375 

injuries  from II.     365,  367 

Erdmann's  blood-stains I.     1 70 

feigned  diseases II.     399 

insanity 11.     410 

Fillmore,  aphasia  and  testamentary  capacity 11.     262 

Fort  Edwards,  wounds,  contused I.     269 

Garfield  (President),  post-mortem  examination I.       43 

Gerhold  vs.  Wyss,  insanity  and  divorce II.     ]  36 

German  courts,  attitude  regarding  divorce,  etc.,  and  insanity II.     133.  134 

Greenwood  cs.  Klein,  insanity  and  undue  influence II.     126 

Guiteau,  insanity  and  crime II.     198 

Gumbault  rs.  Public  Administrator,  lucid  interval II.     113 

Hall  vs.  Warren,  lucid  interval II.     ]  1 3 

hallucinations,  historical II.       33 

Hamilton  cs.  Third  Avenue  R.  R.,  damages  for  mental  distress II.     385 

Harford  vs.  Singleton,  insanity  and  breach  of  promise II.     132 

Harris  (Carlyle),  professional  confidences  of  physicians I.     625 


688  /iVD^x. 

PAGE 

Cases  : 

Hartwell  vs.  MeMaster,  eeeentrieity  and  will n.  120 

Heigham,  wounds,  gunshot . . ; I.  254 

hermaphrodites II.  419 

historical,  of  hereditary  insanity .11.  58 

Howe,  insanity  and  torts II.  143 

Hughes,  wounds,  incised I.  270 

Hui'lehy  vs.  Martine,  false  imprisonment  and  insanity II.  147 

hysterical H.  211 

illustrating  blood-stains I.     170-182 

imperative  concepts H.  45 

insane  motives H.  180 

insurance — warranties  and  representations I.     499-504 

Johnson  vs.  Ai'mstrong,  insanity,  undue  influence,  and  testamentary  ca- 
pacity   II.  125 

Jumel  will,  delusions  and  testamentary  capacity II.  118 

Kennedy  vs.  Standard  Sugar  Eefining  Co.,  damages  for  mental  distress. .  .II.  386 

Klock,  wounds,  gunshot I.  268 

Lancaster  Co.  Bank  vs.  Moore,  contracts  and  insanity II.  131 

Lee  vs.  Scudder,  alcoholism  and  testamentary  capacity II.  125 

Lewis  vs.  Lewis,  insanity  and  annulment  of  marriage H.  136 

life-insurance  policy  on  limatic,  recovery  on II.     145,  146 

Lilly  vs.  Waggoner,  contracts  and  insanity II.  128 

Lynch  vs.  Knight,  damages  for  mental  distress II.  387 

Mclntyre  vs.  Giblin,  damages  for  mental  distress II.  385 

Mclntyre  vs.  Sholty,  torts  and  insanity II.  143 

McNaughton,  "right  or  wrong"  test,  crime  and  insanity II.     175,  218 

MePherson,  insanity  and  testamentary  capacity ; II.  113 

Mallon,  wounds,  gunshot I.  271 

Manley's  Executor  vs.  Staples,  delusions  and  testamentary  capacity II.  119 

Mar.sh,  alcoholism  and  testamentary  capacity II.  124 

Marvin,  banki'uptcy  and  insanity II.  137 

Maybi'iek,  Mrs.,  poisoning,  arsenic I.     357,  369 

Mechanicsville,  wound,  contused,  and  fracture I.  268 

mental  distress,  damages  for II.  385 

mere  distress II.  387 

sense  of  shame II.  386 

m^istaken  diagnosis II.  606 

Mordaunt,  puerperal  insanity  and  divorce II.  135 

Murphy,  bankruptcy  and  insanity II.  137 

Newton  vs.  Mutual  Benefit  Life  Insurance  Comj^any,  insanity  and  insur- 
ance    II.  147 

O'Connor  vs.  Eempt,  habitual  drunkard II.  157 

O'Shea,  wounds,  contused I.  251 

paranoiac  delusions II.  89 

Parish,  aphasia  and  testamentary  capacity II.  261 

Patterson,  habitual  drunkard II.  141 

Peoy)le  vs.  Barber,  mental  responsibility  and  crime II.  233 

Piper,  blood-stains I.  169 

Pomeroy,  imbecility  and  crime II.  86 

Prentis  vs.  Bates,  eccentricity  and  testamentary  capacity II.  119 


INDEX.  689 

PAGE 

Cases : 

Priteliai'd,  poisouiiig,  antimony I.  34S 

puei'j^eral  insanity  and  crime II.  103 

rape,  senile  attempt  at II.  556 

Eavacliol,  insanity  and  crime 11.  184 

Eawdon  vs.  Rawdon,  insanity  and  divorce 11.  133 

Riddle,  Mrs.,  poisoning,  arsenic I.  380 

Riggin,  delirium  and  testamentary  capacity 11.  122 

Rusk,  contracts  and  insanity II.  129 

sexual  perversion II.  556 

contrary  sexuality II.  570 

f etichisra,  body II.  567 

dress II.  56» 

hyperfesthesia  sexualis II.  558 

lust-murder II.  561 

Shattuck,  wounds,  gunshot I.  281 

Sherman,  Mrs.,  poisoning,  arsenic I.  350 

Smith  vs.  Williamson,  habitual  drunkard II.  158 

State  ex  rel.  Setzer  vs.  Setzer,  insanity  and  legitimacy II.  133 

State  of  Connecticut  vs.  Hayden,  blood-stains I.  169 

Steenbergh,  wounds,  contused I.  275 

Summers  vs.  State  of  Texas,  power  to  compel  expert  testimony II.  150 

Thompson,  wounds,  contused  and  lacerated I.  278 

Tiehborne,  identity I.     71,  192 

traumatic  hysteria II.  344 

Underwood  vs.  Wing,  sui'vivorship I.  236 

Victoria  Railway  Commission  vs.  Coultas,  damages  for  mental  distress. . .  II.  388 

Wallis  vs.  Luhriug,  undue  influence  and  testamentary  capacity II.  113 

Watson,  extreme  age II.  ]  17 

Weitzel,  insanity  and  bankruptcy II.  137 

Welsh  "fasting  girl" I.  137 

Weston,  wounds,  incised I.  260 

Wharton,  poisoning,  antimony I.  347 

Whiteehapel  murders,  identity  of  dead  body I.     61,  75 

Wightman  vs.  Wightman,  insanity  and  validity  of  marriage II.  172 

Williams  vs.  Goss,  habitual  drunkard II.  152 

Young  vs.  Young,  alcoholism  and  divorce II.  1 53 

Castration II.  628 

Catalepsy II.  51 

feigned II.  401 

Causes  of  insanity II.  57 

Children  (see  Birth,  Pregnancy,  Sexual  Perversion,  etc.). 

age  of  consent: I.    651 ;  II.  525 

indecent  assault  upon I.    649  ;  II.  525 

limit  of  childhood II.  185 

responsibility  of,  for  ei'ime II.  1 84 

substitution  of,  at  birth II.  459 

suppression  of,  after  birth II.  459 

Chloral,  chloral  hydrate I.  468 

chloral  habit,  a  cause  of  insanity II.  59 

Chlorine,  potassic  chlorate I.  333 


690  IXDEX. 

PAGE 

Chloeoform  (see  Anaesthetics) , I.    466 ;  EC.  596 

Cholix I.  492 

Chorea,  feigned II.  402 

Cicatrices,  identification  by I.  72,  201 

CiRCUMCislox  (see  Grenito-urLiiarT) H.  627 

Claustrophobia  (see  Insanity) II.  45 

Cleft  Palate  (see  Sui"gieal  Practice) II.  610 

Cocaine I.  428 

insanity  due  to  cocaine  habit II.    59,  205,  209 

CocATDTsic  Acid I.  428 

CoccuLrs  Indicus,  picrotoxin I.  473 

Codelst: I.  439 

Colchicum,  eolcMcine,  colchicin,  colcMcia,  colchieina I.  430 

Cold  as  affecting  insurance I.  540 

COLICA  PlCTOROiI I.  394 

Color -BLrsDNESs,  feigned n.  408 

C0M3IISSI0X  in  lunacy II.  138 

appHeation  for II.  142 

traverse  in  finding  of II.  142 

CoJiMiTMEXT  of  the  insane II.  138 

CoioiiTTEE  of  estate,  in  lunacy n.  142 

CoiiPEXSATiox  of  expert  witness 11.  149 

Competency  of  the  insane  to  testify n.  173 

Concepts,  agoraphobia  and  claustrophobia 11.  45 

insistent  and  imperative n.  44 

case  of  imperative  concepts II-  45 

mental II-  28 

normal  and  diseased II-  28 

Concussion  (see  Wounds) I-  287 

of  the  brain  and  of  the  spinal  cord II-  298 

CONTINE,  conium,  coniin,  conine,  conia,  conieine,  eonicina I.  432 

Consumption  as  affecting  insurance I-  529 

Contagious  Diseases,  duties  of  physicians  and  sm-geons  as  to I.  633 

Contracts,  in  legal  relations  of  physicians  and  surgeons I-  604 

insanity  as  affecting II-  173 

Contracture  (see  Surgical  Practice) II-  621 

Contusions  (see  Post-mortem  Examination  and  Wounds) I.  32,  244 

Convulsions  (see  Epilepsy) II-  223 

feigned II-  399 

Copper,  cupric  suli^hate I-  404 

Coroner's  Inquest  (see  Post-mortem  Examination) I.  57 

Corpse,  identity  of  (see  Identity) I-  32 

Corrosive  Poisons  (see  Poisons  and  Post-mortem  Examination) '. I.  33 

Corrosive  Sublimate I-  400 

Courts  of  Law,  rulings  of  (see  Laws,  Cases,  etc-). 

capacity  to  know  right  from  wrong,  charge  of  Chief -Justice  Shaw II.  231 

decisions  recognizing  mental  disease .* II-  251 

delusions  as  a  defense  for  crime II-  230 

legal  views  of  State  courts  regarding  impulse II-  244 

Craniology II-  'i^ 

of  criminals II.  183 


INDEX.  691 

PAGE 

€retinism TT.  85 

Orime,  deaf-miitism  and II.  190 

imbecility  aiul II.  189 

inherited  and  insane  tendencies II.  182 

insane  impulses  toward II.  48 

intoxication  as  an  excuse  for II.  205 

resp(Hisibility  of  children  for II.  184 

sexual II.  525 

signs  of  degeneracy II.  184 

Criminal,  age  of II.  185 

assaults I.  33 

craniology  and  skull  capacity  of II.  183 

legal  relations  of  physicians  and  surgeons  to I.  636 

lunatic II.  182 

Criminal  Kesponsibility  (see  Responsibility) II.  217 

Croton  Oil I.  471 

Cutaneous  Anaesthesia II.  339 

Darwinian  Tubercle I.     70  ;  II.  73 

Datura  Stramonium I.  427 

Deadly  Nightshade I.  424 

Deaf-mutes,  mental  capacity  of II.  158 

deaf -mutism  and  crime II.  190 

feigned  deafness II.  408 

Death,  autopsies,  government  regulation  of I.  57 

causes  of,  medical  testimony  regarding,  in  insurance  cases I.  593 

condition  of  blood  at  approach  of  I.  88 

cooling  of  body  after I.  90 

coroner's  inquest I.  57 

decomposition  and  putrefaction I.  99 

adipocere,  formation  of I.  104 

chronological  order  of I.  105 

external  appearances  of I.  107 

mummification  and  saponification I.  105 

determination  of I.  58 

drowning,  death  by I.  88 

apiiearance  of  mucous  membrane I.  102 

asphyxiation I.  120 

changes  in  appearances  of  features,  of  viscera I.  101 

coldness  of  the  body I.  121 

condition  of  hands  and  feet I.  122 

contents  of  gall-bladder I.  102 

effect  of  temperature  on  decomposition I.  lo:} 

effusion  of  fluid  into  cavities I.  1 02 

fluidity  of  the  blood  after  death I.  99 

injuries  to  body  in  inmning  water I.  129 

internal  examination I.  123 

nature  and  depth  of  fluid I.  130 

paleness  of  the  body I.  121 

pulmonary  apoplexy  and  neuro-paralysis I.  121 

putrefaction,  pressure  of  gases  evolved  in I.  100 

putrefaction  after  drowning. I.  09 


C92  INDEX. 

PAGE 

Death  by  drowning,  relation  io  life  insurance I.  58& 

situation  of  the  tongue I.  122 

water  in  lungs  and  stomach I.     100,  126 

whether  the  result  of  accident,  suicide,  or  homicide I.  128 

due  to  violence I.  58 

electricity,  death  by I.  134 

frost  erythema I.  97 

gi-avitation  of  blood  in  capillaries  after I.  96 

hanging  and  strangulation,  death  by I.  116 

accidental I-  120 

appearance  of  body I.  118 

occurring  before  or  after  death I.  117 

suicidal I-  116 

heat  or  cold,  death  by I.  131 

burning,  consequences  of I.  133 

excessive  heat I.  132 

freezing I.  132 

hue  of  blood I.  132 

hypostases,  post-mortem I.  97 

spontaneous  combustion I.  133 

identity  of  dead  body I.  59 

accidental  or  voluntary  alterations I.     193-196 

age I-     64-66 

anthropological  aids I-  59 

cases,  Whitechapel  murders I.     61,  75 

Tiehborne  claimant - I.  71 

cicatrices I.  72 

Darwinian  tubercle !•  70 

deformities I-  72 

featui'es,  gnathic  index I.    60,  70- 

hair,  color  and  character  of I.  70 

diameter  of I.  74 

human  and  animal I.  7-4 

nose I-  61 

occupation  during  life . , I.  73 

photogi'aphy,  value  of I.  59 

race  characteristics I.  60 

scars I.  71 

sex,  of  mutilated  or  decomposed  bodies I.  61 

of  skeleton I.  63 

stature I-  68 

and  size  of  races I.  60 

figure  carre  for  determining I.  69 

length  of  femur  as  determining I.  68 

Orfila's  and  Sue's  tables I.     68,  69 

tables  of  details  to  be  noted  in  identification I.  75 

teeth,  development  of I-  67 

tattoo  marks I.  72 

medico-legal  aspects  of I.  57 

period  at  which  occurred I.  96 

poisoning,  death  from,  by  illuminating-gas I.  97 


INDEX.  Guar 

PAGE 

Death,  septicemia,  death  from I.  *M' 

signs  of I.     87,  91 

changes  in  the  eye  I.  02 

from  narcotic  poisoning ; I.  9.5' 

rigor  mortis I.     93-95,  99' 

softening  of  muscles  and  tissues I.  93; 

starvation,  deatli  by I-  134: 

baby-favniing I.  1 37 

fades  liij)j)t>cr(ttica I.  137 

Welsh  "fasting  girl  " I.  137 

suffocation,  death  by,  manner  produced I.  108' 

accidental I.  Ill 

anaesthetics,  by I.  1 1 3- 

carbonic  acid,  by I.  115 

dynamical  asphyxia  Ijy  noxious  gases I.  113 

homicide  by I.     111.  112 

internal  occlusion  of  air-passages I.  Ill 

post-mortem  appearances  of I.  1U9 

sewer-gas  and  sulpliureted  hydrogen I.  115 

smoke,  by I.  113 

smothering,  bj" I.  Ill 

vitiated  air,  by I.  112 

suicide  by  carbolic  acid I.  88 

siispended  animation,  by T.     88,  89 

suspension  of  respiration,  by I.  88- 

sjnicope,  by I.  88- 

tests  showing I.  95 

Decomposition  (see  Death  and  Post-mortem  Examination) I.  35 

effects  of  temperatm-e  upon I.  99 

Delirium  (see  Insanity),  acute II.  103 

tremens II.  95 

Delusions  (see  Insanity) II.  35 

as  a  defense  for  crime II.  230 

as  betrayed  in  dress II.  39 

as  symptoms  of  insanity II.  -10 

associated  with  hallucinations II.  39 

case  of,  i  n  paranoia II.  36 

concealet  1 II.  -12 

definition  of II.  35 

erotic II.  44 

fixed II.  42 

formation  of 11.  39 

genesis  of II.  40 

persecutory II.  41 

religious 11.  35 

case  of II.  43 

sane  or  insane II.     35,  2.34 

Swedenborg's  and  Luther's II.  39 

systematizetl  or  unsystematized II.  39 

Dementia  (see  Insanity) II.  46 

acute II.  10» 


,t394  IXBEX. 

PAGE 

De:mentia,  forms  of II.  108 

paretic II.  110 

illusions  due  to  paretic  dementia II.  35 

primary II.  109 

senile II.  109 

Dentists,  professional  standing  of,  before  the  law I.  643 

Detection  of  metallic  poisons I.  54 

Developmental  Ugliness II.  86 

Diathesis,  insane ,. II.  49 

Digitalis,  digitalin,  digitouin,  digitoxin,  digitalein I.  463 

Diploma  as  showing  qualification  of  physicians  and  surgeons I.  637 

Disease,  Bright's I.  537 

cold I.  540 

consumption I.  529 

dyspepsia I.  534 

■eye,  diseases  of  the I.  539 

fits I.  534 

headaches I.  540 

lieart  disease I.  535 

hemoptysis I.  532 

in  relation  to  life  insurance  (see  Insurance) I.  493 

liver,  disease  of  the I.  538 

mastoid II.  612 

narcotics I.  551 

•  opium I.  551 

rheumatism I.  536 

■the  result  of  accident I.  585 

tonsilitis s I.  538 

'Dislocations  (see  Wounds) I.  294 

Distress  (see  Mental  Distress) II.  385 

X>iV0RCE  (see  Marriage  and,  Insanity  and). 

by  consent II.  522 

causes  for,  adultery II.  522 

arising  after  marriage II.  521 

before  marriage II.  520 

cruelty II.  521 

desertion II.  522 

habitual  drunkenness II.  522 

ill  treatment II.  521 

impotence II.     497-503,  520 

insanity II.     133,  521 

cases  of II.     133-136 

loathsome  diseases II.  522 

gonorrhea   II.  505 

syphilis II.  509 

condonation  and  recrimination  as  defenses II.  523 

procedure II.  519 

testimony  in  divorce  suits II.  523 

Dreaming II.  51 

Drowning  (see  Death) I.  88 

■J)RUNKARDS,  habitual  (see  Insanity) II.  152 


IXDJ'JX.  095 

DiTY  of  medical  examiners  for  insurance  companies  I.  "juD 

of  i)liysicians  ami  siirj^eons  as  to  coiita<^ious  diseases I.  ii'S.i 

goiiorrlical  disease II.  auS 

Dy.slkxi  A II.  '2~'2 

Dyspepsia  us  affcctiiif^  insurance I.  'I'-'A 

Eating  of  Iminan  flesli  (see  Insanity) 11.  4'.J 

EcjCKNTKicprY  as  affecting  testamentary  cai)acity II.  1  1 IJ 

EcOHYMOsis  (see  Post-mortem  Examinations  and  Wounds) I.     ^i"),  244 

P^CHOLALIA  (see  Insanity) II.  74 

Elkctric  Currents  of  high  power TI.  '.'.C/.i 

bibliography II.  ;j7t) 

(lea th  fi'om I.      1  .■J4  ;  II.  '.'AH 

autopsies II.  ;jG9 

cases II.     :]m,  309 

effects  of,  upon  the  human  body II.  304 

charges  that  do  not  kill II.  30.5 

.   cases II.     30;)-307 

electric  burning  and  ease  of II.  371 

falls  and  other  injuries  due  to II.  37 1 

medical  electricity,  accidents  from II.  372 

recent  legal  decisions II.  373 

Augusta  Railway  Co.  r.v.  Andrews II.  374 

Burt  vs.  Douglas  County  Street  Eailway   II.  373 

Clements  rs.  Louisiana  Electric  Light  Co II.  373 

Colorado  Electric  Co.  r.s-.  Lubbers II.  374 

Electric  Railway  Co.  rs.  Shelton II.  37.") 

Krantz  vs.  Brush  Electric  Light  Co II.  .374 

Piedmont  Electric  Illuminating  Co.  vs.  Pattesou's  Administrator II.  37.1 

Southwestern  Telegraph  and  Telephone  Co.  rs.  Robinson 11.  .373 

Embalming  as  affecting  putrefaction I.  1  ii4 

Embolism,  fat,  as  a  mishaii  of  surgical  practice II.     oS."),  0(1.3 

Emotion,  disturbances  of II.  4S 

Empyema II.  014 

Epidtdy.mitis  and  crime II.  1 99 

and  idiocy II.  ]8S 

and  indjecility II.  2(10 

and  violence II.  2't() 

as  a  cause  of  sterility II.  r)04 

defined II.  199 

epileptic  insanity II.  93 

feigned  IL     200,  399 

morbid  states  after  convulsions II.  9.'i 

Epilepsy II,  223 

and  aphasia II.  2S4 

Epithelium  from  vagina  (see  Blood-stains) I.  ISO 

Erytheaia,  frost  (see  Death  and  Post-mortem  Examination) I.  97 

Ery'titroxylon  Coca I.  42S 

Ether,  hydrobromic  (see  Anipsthetics  and  Surgical  Practice) II.  003 

Ethylidendiamin  and  ethylendiamin I.  491 

Eustachian  Tube,  catheterization  of II.  012 

ExA:\riN,vTioN,  expert I.  591 


696  IXDEX. 

PAGE 

ExAMiKATiON,  expert,  in  indecent  assault I.  Qb5' 

of  insane  criminals 11.  213- 

physical,  in  accident  cases II.  377 

post-mortem I.  25' 

Examining  Boards,  diplomas  of  physicians  and  surgeons  from I.  598- 

Excise  Laws,  relations  of  physicians  and  surgeons  to I.  638- 

Experiments  on  effects  of  ptomaines I.  485 

Experts,  medical II.  13 

avowal  of  uon-expertism II.  148- 

compensation  of I.     614 ;  II.  149' 

criminal  cases  or  de  lunafico  inqidrendo II.     15,  148- 

duties  and  resiionsibilities  of II.     13,  148- 

English  laws  regarding II.  13 

evidence,  in  surgery  cases II.  574 

value  of II.  17 

examination  of  applicants  for  insiu'ance I.  591 

plaintiff  in  accident  cases II.  377 

hypothetical  questions II.     15,  148 

impartiality  of II.  148- 

qualifications  of II.     148,  177 

questions  for,  in  accident  cases II.  377 

infanticide  cases II.  47& 

use  of  books  in  court II.  14^ 

Extravasation  (see  Woimds) I.  298 

Eye,  diseases  of,  as  affecting  insurance I.  539 

feigned II.  40& 

hysterical  blindness II.  407 

Facies  Hippocratica I.  137 

Fees,  of  medical  experts I.     614  ;  II.  149 

of  physicians  and  surgeons I.     604,  608,  614 

Feigned  Diseases  of  the  mind  and  nervous  system 11.  391 

insanity II.  410 

difficulty  of  feigning II.  411 

special  signs  justifying  suspicion II.  413 

instruments  for  detecting 11.  391 

manliugering II.  392 

danger  to  manlingerer II.  396 

motives  for,  and  fi'eqiiency  of II.     391,  392 

paranoia,  paretic  dementia,  and  dementia II.     413,  414 

pension-office  statistics II.  392 

rules  for  detecting  II.  395 

simulated  motor  symptoms  and  methods  of  detection,  paralysis II.  397 

convulsions,  epilepsy II.  399 

contracture,  catalepsy II.  401 

tremor,  ataxia,  chorea .* II.  402 

simulated  sensory  symptoms  and  methods  of  detection,  antesthesia II.  403 

blindness,  hysterical  blindness II.     406,  407 

hemeralopia,  color-blindness II.  408 

hyperfesthesia  and  pain II.  405 

speech  disturbances II.  410 

sjTinptoms  most  easily  feigned II.  414 


ISDKX.  G97 

PAGE 

Feigned  Diseases,  etc. ,  symptoms  impossible  to  feign II.  395 

deliberately  produced II.  396 

genuine,  cause  feigned II.  390 

Fetichis.m,  body,  and  cases II.  507 

dress II.  508 

cases II.  569 

erotic II.  506 

Fibers  (see  Hairs) I.  187 

Finger  marks  (see  Post-mortem  Examination) I.  32 

impressions  (see  Identity) I.  534 

Fistula,  lacteal II.  014 

Fits  as  affecting  insurance I.  534 

FoLiE  A  Deux II.  95 

FOLIE  CiRCULAIRE II.  91 

Foxglove I.  403 

Fractures  (see  Wounds  and  Surgical  Practice) II.  573 

amputations II.  021 

anchylosis II.  021 

contractures II.  021 

deformities  following II.  014 

extremities II.  014 

gangrene  following II.  017 

hip  disease  in  children II.  019 

injuries  of  hip-joint II.  618 

lower  end  of  radius II.  010 

near  elbow II.  015 

neck  of  humerus II.  015 

resection  of  knee II.  G2(J 

tenotomies  and  myotomies II.  021 

wounds  and  f laetures I.  290 

Frost  Erythema I.  97 

FuGiN I.  492 

Oadinixe I.  492 

•Gelsemium,  gelsemine,  gelsemic  acid,  gelsemin,  gelsemia I.  434 

General  Paresis,  alcoholic  (see  Paretic  Dementia) II.  97 

Oenito-urinary  and  venereal  affections II.  497 

gonorrhea,  lu'ethritis II.  505 

duty  of  physician  advising  marriage II.  508 

clTcft  s  of,  in  producing  sterility II.  508 

upon  offspring II.  508 

iipon  relations  of  sexes  during  man-iage II.  507 

gonococcus II.  505 

modes  of  infection II.  505 

impotence  in  the  male II.  497 

diseases  of  the  kidneys,  bladder,  etc II.  502 

glycosuria II.  501 

malformations II.  498 

masturbation II.  502 

mental  conditions 11.  500 

impotence  in  the  female TI.  502 

hysteria II.  503 


698  INDEX. 

PAGE 

Gexito-urixary,  etc.,  impotence  in  tlie  female,  imperforate  hymen II.  503 

malforuiations 11.  502 

vagiuismus II.  50i> 

sterility  in  tlie  male II.  503- 

blockiug  of  vasa  clef  erentia II.  504 

epididjTiiitis II.  504 

sterility  in  the  female II.  504 

absence  of  ovaries II.  504 

acidity  of  secretions II.  505- 

siu'gical  practice  and  malpractice II.  P>'l0' 

abscess  of  testicle II.  628 

castration 11.  628 

catheterization  and  other  methods II.  626 

permanent II.  627 

eircimicision II-  627 

hydrocele II-  627 

vesical  calculus II.  628 

syphilis , II-  50& 

'  CoUes's  law II.  514 

congenital  and  acquired ; II.  510 

ground  for  divorce II.  513^ 

infection  from  choc  en  vctonr II.  512 

intermittence  of  lesions II.  514 

miscarriages  as  evidence  of 11.  514 

modes  of  infection II.  50D 

GoNOCoccus II.  505- 

presence  of,  in  objects  of~rape II.  536' 

GoxoRRHEA  (see  Genito-uriuary  and  Venereal  Affections) II.  505 

Grubelsucht  (see  Insanity) II.  44 

GrxsHOT  WouxDS  (see  Wounds  and  Surgical  Practice) I.     252  ;  II.  607 

Habitual  Drunkards,  mental  capacity  of II.  152: 

cases II-     152-1.58 

H.€;jiATiN I-  141 

H.EMix I.     158,  162 

HAEMOGLOBIN I-  140 

Hairs  and  Fibers I.  70-74,  195,  196' 

body,  hair  from  human I-  187 

diameters  and  markings  of I-     187-189- 

found  upon  -weapons I.  187 

microscopical  ajipearance  of I.  188 

silk,  wool,  flax I.  189- 

Hallucinations II.  30 

auditory II.  31 

definition  of H.  30 

due  to  alcohol,  belladonna.  Cannabis  Indiea,  hypnotic  suggestion II.  33- 

solitary  confinement H.  33 

forms  of  insanity  in  which  hallucinations  appear   II.  34 

found  alone  and  together     H.  33- 

historical  examples  of II.  33 

mechanism  of 11.  30 

of  feeling II.  32; 


INDEX.  G'J'^ 

Hallucinations,  olfaetive II.  32. 

sensorial  disturbances II.  ;J2 

unilateral II.  'M 

visual II.  ;i(i 

Halogens,  tho I.  'ssa  ■ 

HANDWHiTiNri,  insane,  change  in  character  of II.  T-t 

Hanging  (see  Death  by  Hanging) I.  \\(l- 

Harelip  (see  Surgical  Practice) II.  Oii!>"' 

Headache  as  affecting  insurance I.  540' 

Health,  in  relation  to  insurance   I.     511-al  ^ 

family  record     I.  ')a\ 

habits  as  affecting I.  541 

occupation  as  affecting I.  55(5 

sound I.  519 

tables  of  mortality,  etc I.     511,  512,  530,  550,  551,  557 

wholly  disabled I.  587^" 

Hellebore I.  460 ' 

Hemeralopia,  feigned II.  408  • 

Hemlock I.  432" 

Hemophiliacs II.  58ff' 

Hemoptysis  as  affecting  insurance I.  532: 

Hemorrhage  as  a  mishap  in  surgical  practice II.  586' 

Henbane I.  427' 

Heredity,  as  a  cause  of  insanity II.  5.H' 

of  criminal  instinct II.  59' 

Hermaphrodite II.  418' 

Hernia  (see  Surgical  Practice) II.  G2.> 

cure  of 11.  624 

disturbances  following  operations II.  62.v 

hysterical  atony  simulating II.  624 

Hip  Disease  in  children II.  61!» 

History  of  life  insiirance I.  493' 

Homicide  (see  Death,  Post-mortem  Examinations,  Wounds,  etc.). 

by  drowning I.  128- 

suffocation I.     Ill,  112 

defined I.  24;;- 

Hydrocele II.  627 

Hydroparacumaric  Acid I.  48!V 

Hymen,  anatomical  changes  induced  by  coitus II.  528. 

imperforate,  as  cause  of  impotence II.  50.'i' 

Hyoscyamus,  hyoscyamine,  hyoscine I.  427 

Hyper.'esthesia  Sexualis II.  557' 

Hypnosis  and  auto-hypnosis  in  eases  of  rape II.  541 

hallucinations  due  to II.  33' 

liypnotic  influence II.  212' 

illusions  due  to II.  3.>' 

Hypothetical  Question  (see  Expert) II.  14S. 

Hysteria  (see  Insanity) II.  Olf: 

cases II.  211 

hysterical  atonj'  simulating  hernia II.  62+ 

insnnitv II.  2()!> 


700  INDEX. 

PAGE 

Hysteria,  mercurial I.     399 

responsibility 11.     210 

Identity  of  the  Dead  Body  (see  Death) '. .    .  .1.     32,  59 

determination  of I.     60-73 

Identity  op  the  Living I.     191 

.aecideutal  or  volimtary  alterations  in  appearance I.     3  93 

age,  determination  of I.     64,  194 

■cicatrices  I.     171,  193 

■deformities I.     72,  193 

■disease,  effects  of I.     193,  194 

finger-nails I.     196 

liair,  changes  in I.     195 

classification  of I.     196 

decoloration  of I.     196 

head,  contigiiration  of I.     195 

insanity,  results  of I.     193 

labor,  manual  or  other,  signs  of I.     193 

loss  of  limbs,  teeth,  or  hair I.     193 

pigment  bleaching I.     193 

teeth I.     195 

trophic  changes I.     193 

finger  and  foot  impressions I.     204 

Galton's  method I.     206 

right-  and  left-handedness I.     207 

significance  of  footprints I.     206 

general  appearance I.     21.S 

handwriting,  identification  bj'  means  of I.     203 

history  and  experiences I.     228 

incriminating  circumstances I.     228 

mental  traits I.     226 

mistaken  identity I.     30,  191 

recognition  by  pistol-flash I.     191 

physical  j)eculiarities I.     221 

skin  lesions  and  their  results I.     200 

cicatrices I.     72.  201 

age  of I.     202 

diseases,  evidences  of I.     200 

indelibility  of  marks I.     202 

tattooing I.     72.  202 

.-stigmata  of  occupation I.     73,  197 

hands I.     198 

recognition  of  changes  due  to  occupation I.     1 98 

suggestions  as  to  examination I.     207 

Bertillon's  methods I.     208 

Smart's  and  Greenleaf's  methods I.     211 

unreliability  of  evidence I.     192 

Tichborne  case I.     71 ,  192 

Idiocy,  acquired II.       80 

and  alcoholism II.       80 

and  epilepsy,  and  paralysis II.     188 

and  heredity II.     188 


INDEX.  701 

PAOK 

Idiots,  basis  of  mental  expression  of II.  84 

c'l'iuiiology  of II.  81 

defective  bruin  development  of II.  188 

mental  capacity  of II.  84 

mici'oeephalous II.  80 

l)alatHl  arch,  deforaaity  of II.  81 

pliysical  peculiarities  of II.  80 

]iro}ifiiatliisin II.  81 

sexual  anouuilics  in II.  85 

speech  of II.  84 

suture,  premature  closing  of II.  81 

Illusions  (see  Insanity) II.  34 

definition  of II.  34 

differentiation  of II.  34 

due  to  alcohol 11.  35 

confusional  insanity II.  35 

hypnotic  suggestion II.  35 

paranoia   II.  35 

paretic  dementia II.  35 

Imbecility  (see  Insanity) II.  85 

Imperative  Concepts  (see  Insanity,  Morbid  Impulses) II.  44 

cases  of    II.  45 

Impotence  (see  Genito-urinary) II.  497 

Impulse  (see  Insanity). 

maiiiacal II.  250 

morbid II.  49 

sexual II.  49 

uncontrollable n.     44,  188,  191,  243 

Incest  (see  Sexual  Crimes) II.  547 

anomalous  psychical  state  leading  to II.  548 

defined II.  547 

origin  of  aversion  to II.  548 

punisliment  of II.  548 

Indecent  Assault  upon  children I.  649 

accused  (the)  of I.  652 

age  of  consent I.     651 ;  II.  525 

definition  of I.  649 

examination I.  655 

false  accusations I.  653 

legal  aspect  of I.  649 

penalty  for I.  651 

severity  of I.  653 

varieties  of I.  651 

Indecent  Exposure  (see  Sexual  Crimes) 11.  550 

Indigo-blue I.  489 

Indol,  indoxyl,  indirubin I-  487 

Infanticide  (see  Abortion)  II.     467,  479 

criminal  causes  of  death 11.  491 

drowning 11.  493 

fracture  of  skull • II.  494 

neglect n.  495 


702  INDEX. 

PAGE. 

IxFANTiciDE.     Criminal  causes  of  "death : 

precipitation  into  a  vault II.  493- 

strangulation II.  492 

suffocation II.  491 

wounding II.  494 

defined 11.  479 

natui'al  causes  of  death  in  new-born II.  48& 

accidents  and  injuries II.  49(> 

asphyxia II.  489 

fetal  disease 11-  48^^ 

malformation II.  488- 

maternal  disease II.  491 

questions  for  expert 11.  479' 

air  in  alimentary  canal II.  486- 

artificial  insufflation II.  484 

atelectasis 11-  485 

cardiac  movements II.  486- 

child,  cause  of  death II.  488 

has  it  cried 11.  485- 

how  long  been  dead II.  487 

how  long  did  it  live II.  486- 

was  it  dead  or  alive  at  bii-th II.  482 

was  it  mature II.  480- 

was  it  prisoner's II.  482 

hydi'ostatic  test II.  483 

prisoner,  has  she  been  recently  delivered II.  480 

pulmonary  docimasia II-  485 

putrefaction II.  484 

solidification II.  485- 

Wreden's  test 11.  486 

Inherited  insane  tendencies  (see  Insanity) II.  180 

IxoRGANic  Poisons  (see  Poisons) I.  322 

IxsA>'E,  the. 

appearance  and  conduct  of II-  '*^ 

appreciation  of  nature  of  act,  etc.,  by II.  232 

ai>i)i'^li^iii^ioii  or  removal  of II.  142 

as  witnesses II-  137 

attitude  of II-  '5'6 

capacity  of,  general  questions  relative  to II.  114 

bankruptcy II-  137 

cases II-  137 

breach  of  promise II-  132 

contracts H-     128,  172 

cases II-  129 

deaf-mutes II-  158 

delusions II-  H^ 

cases II-  118 

disease H-  120 

cases II.     121-125 

divorce  and  anuTilment II-  133 

cases II-     134-136 


INDEX.  70;; 

PACK 

Insane,  llie.     Capacity  of,  general  questions  relative  to : 

eccentricity II.  119' 

cases II.  120 

general  symptoms  incapacitating II.  lli> 

impeachment  oi"  public  officer.s II.  144 

influence  of  general  diseases II.  1 20 

legitimacy II.  133 

marriage II.     131,  171,  518 

old  age  and  dementia II.  1 1  <"> 

cases II.  117 

partnership,  dissolution  of II.  144 

suicide II.  128 

testamentary  capacity II.  115- 

undue  influence II.     1 25,  172 

commission  on II.  138 

Dickie  case II.  139 

retrospective  finding  of  a  jury II.  141 

traverse  in  fliuling  of II.  142" 

application  for  traverse II.  142 

commitment  of II.  138 

committee  of  estate  of II.  142 

competency  to  testify  of II.  17.3 

contracts  of II.  Vl^ 

deeds  and  other  instruments  of II.  114 

dehisions  of II.  234 

dress  of II.  78 

emotions  and  will  of II.  242 

evidences  of  design  in II.  232 

examination  of II.  150 

liability  of  custodians  of II.  147 

for  ci\dl  damages  of II.  172 

libels  and  slanders  by II.  143 

maltreatment  of II.  147 

motive  or  absence  of  motive  in II.     180,  234 

museidar  condition  of II.  78 

progeny  of II.  58 

responsibility  of II.  128 

restraint  of II.  142 

testamentary  capacity II.  115 

torts  by II.  143 

writing  of II.  74 

Insane  Diathesis II.  40 

Insane  Impvlses II.  4s 

Insanity,  acute  mania II.  60 

adolescent II.  90 

alcoholic II.     95,  LV_> 

alcoholism II.  50 

habitual  drunkards II.  152 

cases  of II.     152-158 

alternating II.  91 

aphasia II.     259-29C» 


04  IXDEX. 


PAGE 

Insanity,  bedsores  in II.  79 

bibliography  and  index II.     160-167 

capacity  (see  Insane,  capacity  of) II.  114 

eases  beai"ing  on  insanity : 

aleoholismCVon  Ki-afft-Ebing's) H.  206 

aphasic  affections II.     289-296 

Ayer  vs.  Enssell,  false  imprisonment II.  147 

Baker  vs.  Baker,  divorce II.  142 

Banker  vs.  Banker,  divorce II.  142 

Banks  vs.  Goodfellow,  testamentary  capacity II.     118,  170 

Bell  vs.  Bennett,  annulment  of  marriage II.  136 

Blakely  will II.  121 

Bliss  vs.  C.  &  P.  E.  R.  E.,  habitual  drunkard II.  158 

Blodgett,  habitual  drunkard II.  153 

Boyd  vs.  Eby,  medico-legal ;  lucid  interval II.  113 

Brady  will II.  117 

brain  tolerance  to  injiiry,  New  England  blasting 11.  21 

Brown  vs.  Howe,  torts II.  143 

Brown  vs.  Eiggin,  will II.  122 

Carter  vs.  Beckwith,  contract II.  142 

Cherbonnier  vs.  Evitts,  will II.  122 

delusions,  insane II.     235-241 

Dickie,  commission  in  lunacy II.  139 

Dickinson  vs.  Barber,  degree 11.  144 

Dills  vs.  State  of  Indiana,  expert  fees II.  150 

Ducker  vs.  Whitson,  contract II.  130 

Eddy  will II.  117 

Fillmore,  testamentary  capacity II.  262 

Gerhold  vs.  "Wyss.  divorce II.  136 

German  courts,  divorce II.     133,  134 

Gombault  r.s.  Public  Administrator,  medico-legal;  lucid  interval II.  113 

Greenwood  vs.  Klein,  imdue  influence II.  126 

Guiteau,  crime II.  198 

hallucinations II.  33 

Hartwell  r.v.  M'Master,  testamentary  capacity II.  120 

historical  lieredity II.  oS 

Howe,  torts II.  143 

Hm'lehy  vs.  Martine,  false  imprisonment II.  147 

hysterical II.  211 

imperative  concepts II.  45 

insane  motives II.  ISO 

Johnson  vs.  Annstrong,  testamentary  capacity II.  125 

Jumel  will,  testamentary  capacity II.  118 

Lancaster  County  Bank  vs.  Moore,  contract II.  131 

Lee  r.s-.  Seudder,  testamentarj'  capacity 11.  125 

Lewis  vs.  Lewis,  annulment  of  marriage II.  136 

life  insurance,  recovery  of II.     145,  146 

Lilly  vs.  Waggoner,  contract TI.  128 

:McIntyre  vs.  Sholty,  torts TI.  143 

McXaughton,  "  riglit  or  wrong  "  test II.     175.  218 

McPherson,  testamentary  capacity II.  113 


INDEX.  70,3 

PAGE 

Insanity,  casea  bearing  on  : 

Mauley's  Executor  r.y.  Staples,  testamentary  capacity II.  119 

Marsh,  testamentary  capacity 11.  124 

Marvin,  bankruptcy II.  137 

Mordannt,  divorce II.  135 

Muri)liy,  bankruptcy II.  137 

Newton  vs.  Mutual  Benefit  Life  Insurance  Co.,  insurance II.  147 

O'Connor  vs.  Rempt,  habitual  dnnikard II.  1.17 

paranoiac  delusions II.  s'.> 

Parish,  testamentary  capacity II.  2')! 

Patterson,  habitual  drunkard II .  141 

People  vs.  Barber,  mental  responsibility II.  233 

Pomeroy,  crime II .  SO 

Prentis  vs.  Bates,  testamentary  cajjacity II.  119 

puerperal,  and  crime II.  103 

Kavachol,  crime II.  184 

Kawdou  vs.  Rawdon,  divorce II.  133 

Riggin,  testamentary  capacity II.  1 22 

Rusk,  contract II.  12!) 

Setzer  vs.  Setzer,  legitimacy II.  1 33 

Smith  vs.  Williamson,  habitiuil  druidvard II.  158 

Summers  vs.  State  of  Te.xas,  expert  fees II.  150 

Wallis  vs.  Luhring,  undue  influence 11.  113 

Watson,  testamentary  capacity II.  117 

Weitzel,  bankruptcy II.  KiT 

Wightraan  vs.  Wightman,  marriage II.  172 

Williams  vs.  Goss,  habitual  drunkard II.  1 52 

Young  vs.  Young,  divorce II.  153 

causes  of : 

alcoholism II.  50 

Bright's  disease II.  (iO 

cardiac  lesions II.  (iO 

child-bearing  and  illegitimate  pregnancy II.     (iO,  (il 

cocaine,  chloral,  or  02)ium  liabits II.  5!) 

depletion II.  (iO 

direct  and  iiulirect II.  5!) 

emotional II.  51) 

environment II.  5!) 

excessive  se.xual  excitement IT.  (U 

feigaiing II.  (U 

fright II.  (il 

grief IT.  (il 

heredity,  historical  cases II.  5S 

injuries  to  the  brain II.  (il 

intracranial  disease II.  (12 

la  grippe II.  (io 

masturbation II.  ()(• 

overwork II.  5!) 

phthisis II.  ()() 

predis])osing II.  51) 

rheumatism II.  GO 


706  INDEX.  ■ 

PAGE 

Insanity,  causes  of : 

septic  poisoning II.  61 

shock II.  61 

syphilis II.  59 

uterine  and  ovarian  disease II.  60 

classification  of II.  54 

convulsions  in II.  78 

course  and  termination  of II.  62 

eraniology  of II.  73 

curability  of II.  62 

cutaneous  anaesthesia  in II.  78 

death  from  exhaustion  in II.  62 

definitions  of,  legal II.     53,  178 

medical,  by  Bucknill II.  53 

Hamilton II.     54,  56 

Maudsley II.     53,  57 

Spitzka II.  53 

Von  Krafft-Ebing II.  55 

d.elusional  (primary) II.  86 

drunkards,  habitual II.  1 52 

epileptic II.     93,  223 

■epochal II.  55 

expert  witnesses II.     113,  148 

case,  Dills  vs.  State  of  Indiana II.  150 

feigned II.  410 

hallucinations II.  30 

heart  failure  in II.  63 

ieredity  as  a  cause  of II.  58 

inherited  tendencies II.  1 82 

of  criminal  instinct II.  59 

homicidal II.  45 

Irypnotism II.  212 

hallucinations  due  to II.  33 

illusions  due  to II.  35 

liysterical II.     48,  50,  93,  209 

Ja  grnndc  hi/sterie II.  209 

responsibility  of  hysteric II.  210 

insane  tendencies  in II.  182 

intellectual II.  86 

lucid  intervals  in II.  222 

-mania II.     93,  ]00 

mattoids II.  52 

medico-legal  aspects  of • II.  19 

commission  on  ^ 

commitment  of  /   (see  Insane), 

committee  of  estate  of  ' 

legal  definitions  ;  general II.     53,  1 78 

degree  of  insanity II-  144 

English  decisions II.  1 79 

German  decisions II.  1 78 

judge's  charge II.  178 


L\DEX.  707 

PAGE 

Insanity.     Legal  definitions,  etc.  : 

of  lucid  intervals,  uon  compos  /«('/( //x, unsoundness  of  mind II.  1 1  :< 

province  of  the  court II.  r)4 

medical  definitions II.      ')'.i-')7 

medical  expert II.  11."! 

megalomania II.  >i7 

melancholia 11.     Oi),  98,  191 

memory,  affections  of II.     4G,  47 

monomania , II.  86 

moral II.     liUU,  252 

morbid  desires II.     49,  .")i ' 

morbid  impulses II.      1  SO,  191 ,  242 

imperative  concepts II.  44 

cases  of II.  4.") 

neurasthenia IT.  211 

paranoia II.  s(i 

paretic  dementia II.  (59 

partial II.     113,  224 

periodical II.  91 

physical  signs  of  : II.  70 

bones,  brittleness  of II.  79 

brain,  appearance  of  convolutions  of II.  G7 

asymmetry  of II.  (57 

atrophy  of II.  (is 

configuration  of II.  6.1 

hypera?mia  of II.  GS 

increase  in  size  of II.  G8 

lesions  of  the  blood-vessels  of II.  GS 

meningeal  inflammation II.  Git 

microcephalous  (Ireland) II.  G7 

morbid  anatomy  of,  in   acute  mania,  melancholia,  and  paretic   de- 
mentia   II.  69 

specific  gravity  of II.  65 

■weight  of II.  6.") 

in  imbeciles  and  idiots II.  G() 

digestion  and  appetite II.  79 

«ar II.  7S 

eye II.  7S 

secretion  of  tears II.  79 

face,  expression  and  furrows  in II.  7.'j 

■      skin  in II.  !»7 

teeth  in II.  7;> 

temperature  in II.  79 

tendinous  reflexes  in II.  7S 

microscopic  appearances  of  nervous  tissue II.  G9 

trophic  disorders  in II.  79 

urine  in II.  79 

post-febrile II.  107 

after  typhoid II.  108 

prognosis  of IT.  63 

puerperal,  and  cases IT.  103 


708  IXDEX. 

PAGE 

IssANnTT,  quenilent II.  88 

reasoning II.  91 

somatic II.  55 

speech  distm-banees  associated  with  aphasia II.  283 

suicidal II.  45 

symptoms  of,  favorable  and  unfaA'orable  (tabulated) II.     64,  65 

total II.  222 

traumatic II.  105 

after  surgical  operations II.  107 

due  to  .slight  shocks II.  105 

loss  of  memory  in II.  107 

traverse II.  142 

application  for II.  142 

case,  Baker  rs.  Baker II.  142 

Verrucktlteit,  priinare II.  56' 

sensorieUe II.  3-t 

IxSA^JiTT  AivD  AxNULMEKT  OF  IMakkiage  (see  Insane,  capacity  of) II.  135- 

marriages  contracted  in  e.xtrcini>< II.  135 

cases,  Lewis  rs.  Lewis II.  135 

BeU  vs.  Bennett II.  136 

IxsAXiTY  AST)  Bankruptcy  (see  Insane,  capacity  of) II.  137 

cases,  Marvin,  Murphy,  Weitzel II.  137 

IXSAXITY  AND  BREACH  OF  PROMISE II.  132 

case,  Harford  vs.  Singleton II.  132 

INSANITY  AifD  Crime  (see  Crime  and  Responsibility) II.     175,  217 

bibliogi-aphy  of II.  214 

examination  of  insane  cidminals II.  213 

expert  testimony  regarding II.  177 

heredity  of  criminal  instinct II.     58,  59 

individual  responsibility II.  213 

insane  criminals 11.  182 

relationship  between II.  176 

special  forms  of  insanity  in  relation  to  crime II.  184 

alcoholism II.     59,  1 23,  205 

ei)ileptic  insanity II.  199 

Guiteau  case II.  198 

moral  insanity II.  200 

paretic  dementia II.  202 

toxic  insanitj'^ II.  205 

INSANITY  AND  DIVORCE II.      133,  521 

cases  :  Banker  vs.  Banker II.  133 

Gerhold  vs.  Wyss II.  136 

Le^^is  vs.  Lewis II.  1 36 

Mordaunt II.  1 35 

Rawdon  rs.  Rawdon II.  133 

Setzer  rs.  Setzer II.  1 34 

decisions  of  Gennan  courts  regarding II.     1 33.  134 

innocently  acquired  insanity -  II.  1 34 

laws  of  Gennan  Protestant  Church II.  1 34 

plea  of  non-support 11.  1 36 

IXSANITY   AND   LEGITIMACY II.  133 


INDEX.  709 

PAOE 

IXSANITY  AND  LiFE  INSURANCE II.  145 

cases  :  Baron  von  Lindeaau II.  145 

Legi-and  du  SauUe's II.  ]  4G 

Newton  vs.  Mutual  Benefit  Lift-  Insurance  Co II.  147 

Insanity  and  Marriage II.  131 

capacity  to  consent  to  marriage II.  518 

Inspection,  medico-legal  (see  Post-mortem  Examination) I.  25 

Insurance : 

accident  insurance  and  benefit  associations I.  583 

"  accident "  defined I.  583 

beneficial  societies I.  587 

special  statutes  regarding  them I.  58S 

death  from  drowning  as  an  accident I.  586 

disease  the  resiUt  of  an  accident I.  585 

injury  without  visible  sign I.  587 

negligence I.  587 

poison I.  586 

"  wholly  disabled  " I.  587 

life  insurance I.  493 

history  of I.  493 

(fl),  legal  features I.  498 

answers-,  incomjjlete  and  omitted I.  504 

superfluous I.  506' 

beneficiary I.  506 

cases I.     507,  50S 

warranties  and  representations I.  498 

cases I.     499-504- 

(6)  medico-legal  relations  to I.  509 

disease,  freedom  from I.  523 

diseases  legally  commented  on  : 

Bright's  I.  537 

cold I.  540 

consumption I.  529 

dyspepsia I.  534 

fits I.  534 

headaches I.  540 

heart  disease I.  535 

hemoptysis I.  532 

insanity TI.  145 

of  eye I.  539 

of  liver I.  538 

rheumatism I.  536 

tonsilitis I.  538 

family  record I.  554 

habits I.  541 

medical  attendance I.  514 

medical  examiner I.  510 

mortality  (see  Tables) I.  511 

narcotics I.  556 

opium  liabit I.  551 

other  insurance I.  562 


710  IXDEX. 

PAGE 

IxsuRAXCE.     Life  insTiranee,  medieo-legal  relations  to  : 

prior  rejection I.  564 

residence I,  560 

sound  health I.  519 

suicide I.  565 

(c)  obligations  of  insured  and  insurer I.  591 

causes  of  death,  inquiry  into I.  593 

expert  examination I.  591 

relation  of  medical  profession  to  insui-ance  companies I.  591 

(d)  tables  of  actual  and  computed  rates  of  mortality I.  511 

of  comparative  mortality  in  tuberciilar  and  heart  diseases  . .  I.  512 

of  deaths  from  consumption I.  530 

of  mortality  in  different  occupations I.  557 

of  relative  mortality  of  intemperate  persons I.  550 

INTELLIGENCE,  test  of II.  20 

Intoxication  (see  Alcoholi-sm,  Insanity) II.  205 

from  fibiin  ferment  (see  Sm-gieal  Pi'actiee) .II.  585 

Iodine,  xjotassium  iodide I.  335 

Iron,  ferric  chloride,  ferrous  sulphate I.  413 

Ieregulap.  Practitioner,  disabilities  of I.  602 

Irritation,  sexual 11.  51 

IS0A3IYLA3IINE I.  491 

Jasmine,  yellow I.  434 

Jervine I.  460 

Katatonla II.  51 

KLEPT03IANIA II.  102 

XiAWS  (see  Courts  and  Cases). 

affecting  benefit  insm-anee  companies I.  588 

autopsies,  laws  regulating I.  27 

Fi*ench  and  German  systems I.  57 

capacity  to  know  right  from  wi-ong II.     178,  179,  231 

charge  of  Chief -Justice  Shaw II.  231 

c-riminal  liability  for  siirgieal  malpractice 11.  583 

criminal,  responsibility  of , II.  217 

defining  insanity,  unsoundness  of  mind,   noii  compos  mentis,  lucid  inter- 
vals  n.     113,  114,  217,  222 

Sir  John  Nieoll's  opinion  of  lucid  intervals II.  114 

divorce II.  519 

English,  on  medical  expert II.  13 

on  sodomy II.  545 

excise,  relation  of  physicians  and  surgeons  to I.  638 

expei"t  testimony II.  14 

Prench,  on  wills  and  testamentary  capacity II.  266 

Oennan,  on  insanity  and  divorce II.  133 

German  Prote.stant  Church,  on  divorce II.  134 

indecent  assault I.  649 

legal  procedures  against  surgeon,  in  eases  of  pregnancy,  delivery,  etc II.  465 

in  commitment,  etc.,  of  in.sane II.     138-142,  147 

legal  relations  of  physicians  and  surgeons  to  their  patients  and  to  one 

another I.  595 

abortion I.  638 


INDEX.  711 

pa<;k 
Laws.     Legal  relations  of  physicians  and  surgoous,  etc.  : 

agents I.  Gil 

contract  and  fees L  G04 

criminal  offenses I.  g;jO 

dentist,  standing  of I.  G4:j 

diploma,  proof  of I.  G37 

duty  as  to  contagions  diseases I.  G.'J.'J 

examining  boards I.  598 

excise  laws I.  638 

fees,  contingent I,  615 

expert  witness I.  614 

who  is  liable  for I.  608 

gi'ateful  patients I.  638 

irregular  practitioners,  disabilities  of I.  596 

legislative  restrictions L  595 

libel I.  640 

license  laws,  medical,  theory  of I.  596 

licenses I.  598 

malpractice  (see  Surgical  Practice) II.  583 

medical  societies I.  639 

obligation  to  obey  a  call I.  606 

to  record  births II.  417 

partnerships I.  635 

pharmacists,  standing  of I.  646 

practice  of  medicine,  what  is  proof  of I.  602 

prescription,  ownership  of I.  636 

professional  confidences I.  616 

Carlyle  Harris  case I.  625 

registration I.  600 

sanctity  of  the  patient's  person I.  632 

slander I.  640 

unprofessional  conduct I.  599 

waiver I.  626 

license  laws,  medical,  theory  and  constitutionality  of I.  596 

life  insurance I.  498 

marriage 11.  517 

rape II.  525 

Lkau I.  391 

Lesbian II.  50 

Liability  of  custodians  of  the  insane II.  147 

Libel  on  physicians  and  surgeons I.  640 

Licenses  (see  Examiinng  Boards) I.  598 

Life,  accepted  period  of  (see  Death) I.  58 

Life  Insurance  (see  Insurance) I.  493 

Lithotomy II.  629 

Liver,  diseases  of,  as  affecting  insurance I.  538 

Lucid  Intervals  (see  Insanity) II.     113,  222 

Sir  John  XicoU's  opinion  of II.  114 

LrsT-MURDER II.  561 

Magendie's  Solution  (see  Morphine) I.  440 

Malixoering  (see  Feigned  Diseases) II.  392 


712    ,  IXDEX. 

PAGE 

Maltreatjiext  of  t  he  insane II.  147 

Mania  (see  Insanity) II.     100,  193 

acute II.  100 

clirouie II.     100,  102 

course  of II.  102 

defined II.  193 

recoveries  in,  percentage  of II.  103 

removal  of  inhibitory  restraint II.  194 

sudden  passion  and  frenzy  in II.  194 

synij)toms  of II.  101 

JklAXrSTUPRATIOX II.  545 

Marriage,  age  of  consent I.     651 ;  II.     517,  525- 

capacity  to  consent II.  51S 

cousinumate II.  518 

contracted  in  cxtroiiis II.  135 

definition  of II.  517 

disqualification  from  relationship II.  519 

effect  of  disqualifications II.  519 

paternity  of  childi-en II.  519 

physical  conditions  rendering  marriage  invalid II.  427 

impotence  and  sterility II.     497.  504 

in  females II.     428-431 

in  males II.  427 

Mastoid  Disease II.  612^ 

Meadow  Saffrox I.  430 

Mecoxio  Acid I.  440 

Medical,  attendance  in  insurance  cases I.  514 

ease  of  Pi'ice  vs.  Life  Insiu-ance  Co • I.  514 

compensation I.     614 ;  II.  149 

examiner  in  relation  to  insurance I.  510 

attendance I.  514 

duties  of I.  509 

expert  (see  Expert) II.     13,  148 

profession  (see  Laws.  Legal  Eelations.of  Physicians  and  Surgeons) I.  595 

relations  to  insurance I.  591 

societies I.  639 

testimony  (see  Expert) II.     13.  148 

as  to  cause  of  death  in  insxirance  cases I.  593 

Medico-legal  (see  Laws) I.  595 

aspects  of  death I.  57 

inspection I.  25 

relations  in  insanity II.  19 

in  life  insiu'ance I.  509 

Megalomaxia  II.  87 

Melancholia  (see  Insanity) II.  98 

agitata II.  99 

chronic II.  100 

ci'imes  of II.  193 

defined II.     98,  191 

delusions  in II.  100 

depression  in II.  191 


INDEX.  713 

PAGE 

Melancholia,  "  desire  to  hang" II.  192 

feigned II.  410 

hypochondriacal II.  99 

simple II.  98 

stuporous II.  99 

symptoms  of II.     98,  191 

uncontrollable  impulse  in II.  192 

Mkmory  (see  Mind) II.  47 

Menopause II.     418,  435 

Menstruation II.     418  431 

menstrual  blood-stains I.  179 

Mental  Defect  and  Disease  in  relation  to  criminal  responsibility  (see  Re- 
sponsibility)  II.  217 

Mental  Distress  as  an  element  of  damage II.  385 

eases  :  Hamilton  vs.  Third  Avenue  R.  R II.  385 

Kennedy  vs.  Standard  Sugar-refining  Co II.  386 

Mclntyre  vs.  Giblin II.  385 

mere  mental  distress,  eases II.  387 

Lynch  vs.  Knight II.  387 

Victoria  Railway  Commission  vs.  Coultas II.  388 

sense  of  shame II.  386 

Hercury I.  396 

Methylguanidine I.  491 

Microorganisms  in  wound  diseases  (see  Surgical  Practice) II.  589 

Microscope,    microscopic    appearances   of   diseased    nei'vous    tissue   in   in- 
sanity   II.  G9 

microscopic  appearances  of  hairs  and  fibers I.  188 

examination  of  blood-stains I.  167 

MiCROSPECTROSCOPE  (see  Spectroscope) I.  143 

Mind  (see  Insane,  etc.) II.     19,  28 

apparatus  of H.  27 

localization  of II.  27 

apperception  of II.  19 

concepts II.  28 

delusions II.  30 

feeling II.  28 

hallucinations II.  30 

ideation II.  28 

illusions II.  34 

judgment II.  28 

memory,  aifections  of II.  40 

forgetf ulness  of  substantives  and  proper  names II.  47 

loss  of II.  47 

mental  aberration,  influence  of,  upon  capacity  of  the  individual II.  112 

elements,  normal  and  diseased II.  28 

weakness II.  29 

relation  of  intelligence  to  complexity  of  nervous  system II.  20 

sensation II.  28 

thinking II,  28 

unsoundness  of II.  113 

volition II.  28 


714  ■  INDEX. 

PAGE 

Mistaken  Identity  (see  Identity) I.     30,  191 

Monk's-hood I.  421 

Monomania  (see  Insanity) II.  86- 

Moral  Insanity  (see  Insanity) II.     200,  252 

defined 11.  20O 

doctrine  of II.  201 

moral  sense II.  201 

Morbid  Desires  (see  Insanity) II.  4f> 

contrary  sexuality,  Lesbians,  sexual  perverts,  nymphomania,  satyriasis . .  II.  SO' 

eating  human  flesh  and  fgeees II.  49 

fear  of  poisoning II.  49 

Morbid  Impulses  (see  Insanity) II.     180,  191,  242: 

imperative  concepts II.  44 

cases  of II.  45- 

Morphine I.  439 

habit II.  207 

insanity  diie  to II.  205- 

Mortality  (see  Insurance) I.  511 

Mummification I.  105 

Murder  (see  Blood-stains,  Crime,  Death). 

cases  :  Billings,  gunshot I.  263 

Briggs,  gunshot I.  262' 

Budge  (Mrs.),  knife I.     249,  259,  273,  277 

Commonwealth  vs.  Piper I.  169- 

Cramer  (Jennie),  arsenic I.  381 

Garfield,  post-mortem  examination I.  43 

Guiteau,  murder II.  198 

Harris  (Carlyle),  professional  confidences I.  625 

Heigham,  shooting I.  254 

Hughes,  stabbing I.  270 

Klock,  shooting I.  268 

McNaughton,  murder II.     175,  218 

Mallon,  shooting I.  271 

Maybrick  (Mi-s.),  poisoning I.     357,  369 

Meehanicsville,  skull  fracture I.  268 

O'Shea,  cutting I.  251 

Pritchard,  poisoning I.  343 

Ravachol,  murder II.  184 

Eiddle  (Mrs. ),  poisoning I.  380 

Shattuck,  shooting I.  281 

Sherman  (Mrs. ),  poisoning I.  350 

Steenbergh,  contusions I.  275 

Thompson,  contusions I.  278 

Weston,  cutting I.  260 

Wharton,  poisoning I.  347 

Whitechapel,  identity  of  bodies I.     61,  75 

Muscular  Sense,  disturbance  of II.  32 

Mutism,  feigned  (see  Deaf -mutism) II.  409 

Mydaleine I.  492 

Mydatoxine .' .  I.  492 

Mydriatic  Alkaloids I.  427' 


ISDLX.  715 

PAOE 

MVOTO.Ml  KS II.  621 

Mytilotoxixk I.  492 

Narceine I.  440 

Narcotics  as  affecting  insurance I.  551 

Xarcotixe I.  439 

Nasal  Ixdex  (see  Identity) I.  Gl 

Negligence  as  affecting  insurance I.  587 

Neurasthenia II.  211 

as  an  excuse  for  crime I.  21 2 

Neurine I.  492 

Nicotine,  nicotin,  nicotia,  nicotina,  Xicotiaita  Tahacum I.  4o7 

Nitrous  Oxide  (see  Anaesthetics  and  Surgical  Practice) II.  603 

NoN  Compos  Mentis  (see  Insanity,  medico-legal) II.  113 

Nux  Vomica I.  447 

Nymphomania II.  50 

Obligations,  of  insured  and  insurer I.  591 

of  physician  and  surgeon  to  obey  a  call I.  606 

Obstetrics  (see  Birth,  Pregnancy,  and  Surgical  Practice) II.     459,  463 

Cfesarean  section II.     456,  459,  460 

Occupation",  as  affecting  insurance I.  556 

as  a  clue  to  identity I.     73,  197 

Oil  of  Vitriol I.  329 

Opium I.  439 

habit,  as  affecting  insurance I.  551 

as  cause  of  insanity II.  59 

Organic  Poisons  (see  Poisons) I.  415 

Orpiment I.  387 

Oth.ematoma II.  78 

Para,  parakresol I.  490 

Paracentesis  abdominis II.  623 

Paradoxia  sexualis II.  555 

Paresthesia  sexualis II.     555,  559 

Paralysis,  feigned II.  397 

Paraxoia,  monomania,  intellectual  insanity,  pai'tial  insanity,  primary  delu- 
sional insanity  (see  Insanity) II.     S6,  195 

and  crime II.  196 

cases II.     88-90 

Guiteau II.  198 

defined II.  195 

delusions  (^vith) II.  87 

of  grandeur II.  197 

of  infidelity II.  197 

of  persecution II.     87,  196 

development  of II.  89 

feigned II.  413 

hallucinations  in II.  87 

illusions  due  to II.  35 

litigiosa,  or  querident  insanity 11.  88 

megalomania II.  87 

reformatory II.  .'^7 

sensorielle  Verriicktheit  ....>, II.  89 


716  IXDEX. 

PAGE 

Paraxoia,  mouomauia,  etc.,  sjanptoms  of II.  86 

violeuce  in II.  197 

Paraphasias II.  268 

Paretic  Dementia,   general  paresis,  general  paralysis,  paralytic  dementia 

(see  Insanity) II.     110,  202 

andcriiie II.  202 

apparent  lucid  intervals  in II.  112 

convulsions  in II.  Ill 

■dementia  in II.  Ill 

■duration  of II.  112 

emotional  state  in II.  Ill 

feigned II.  413 

moral  weakness  in II.  Ill 

periods  of  remission  in II.  Ill 

symptoms  of n.     110,  203 

delusions  of  grandeur  in II.  110 

extravagance  in II.  Ill 

gait  in II.  Ill 

illusions  in II.  35 

pupils  unequally  dilated  iu II.  Ill 

silliness  in II.  204 

speech  clumsy  in II.  Ill 

tremor  in II.  204 

Partnership  between  practitioners I.  635 

dissolution  of,  by  reason  of  insanity II.  144 

Passivism  and  sexual  perversion II.  564 

Patoammine I.  491 

Pellagra I.  480 

Penis,  retraction  of,  in  droAvniug I.  122 

Periodical  Insanity,  folic  cireulaire,  alternating  insanity  (see  Insanity) II.  91 

Pharmacists,  professional  standing  of I.  646 

Phenol,  phenyl  hydrate I.  469 

oxj'phenyl-acetic  acid I.  490 

Phosphorus I.  336 

PiQUERS II.  48 

Poison,  by  illuminating  gas I.  97 

definition  of I.  321 

as  affecting  insurance I.  586 

effects  of  a  poison I.  321 

true  poisons I.  321 

fear  of  (see  Insanity) II.  49 

narcotic,  signs  of  death  in I.  95 

Poisons,  Inorganic I.  S21 

alkalies  and  their  salts I.  322 

ammonia I.  324 

analysis  of I.  326 

caustic  effects  of I.  325 

cerebral  effects  of I.  325 

chemical  analyses  of I.  324 

fatal  doses  of I.  323 

post-mortem  appearances I.  323 


L\i)i:x.  717 

PAGE 

Poisons,  Inorgaxic.     Alkalies  and  their  salts : 

potash  and  soda I.  322 

symptoms I.  322 

time  of  death I.  323 

treatment I.  323 

antimony I.  341 

antimouiureted  hydrogen I.  349 

antimony  chloride,  butter  of  antimony I.  348 

history  of I.  341 

preparation  and  properties  of I.  342 

separation  from  organic  material I.  347 

tests I.  346 

Wharton  ease I.  347 

arsenic I.  349 

amoiuit  necessary  to  prove  poisoning I.  381 

amounts  of,  found  in  body I.  380 

Jennie  Cramer  case I.  381 

Riddle  case I.  380 

detection  after  long  periods I.  383 

distribution  in  the  body I.  378 

elimination I.  382 

examination  of  drugs,  food,  vomit,  etc I.  377 

Mstory 1.  349 

aqua  toffana I.     350,  490 

Sherman  case I.  350 

ice-cream  poisoning I.  355 

metallic  arsenic I.  355 

modern  statistics  regarding I.  351 

accidental  deaths.  New  York  City I.  352 

deaths  from  poisoning  and  from  arsenical  poisoning I.  351 

occiu-renee  in  uatm-e I.  352 

in  the  arts I.     353,  388 

possibility  of  distinguishing  ante-  from  post-mortem  arsenic I.  385 

separation  of,  from  the  tissues I.  377 

soluble  salts,  Paris  and  Schweinfurth  greens I.  388 

tests  :  for  arsenic  in  pure  solutions I.  373 

for  arsenic  in  complex  solutions I.  374 

for  solid  arsenic I.  372 

arsenic  acid,  arsenates,  arsine,  arseniureted  hydrogen,  sulphides I.  386 

arsenic  in  graveyards I.  353 

in  wall-papers  and  other  fabrics I.     354,  388 

arsenical  poisoning I.  361 

acute  and  sub-acute I.  358 

appearance  of  first  sjTiiptoms I.  359 

arsenic  eating I.  368 

Maybrick  case I.  369 

cerebral  or  narcotic I.  361 

chronic  cases  of I.  362 

chronic  symptoms  after  large  doses  and  peculiar  lesions I.  365 

dangerous  and  fatal  doses I.  367 

distiu'banees  of  sensation  and  of  motion I.  364 


718  IXDEX. 

PAGE. 

Poisons,  Ln-organic.     Ai'senieal  poisoniug : 

illustrative  cases I-  360 

poisoning  by  external  application I.  367 

post-mortem  appearances  of  body I.  371 

of  organs I.  371 

prognosis  and  treatment I.  367 

symptoms !•  363- 

time  of  death I-  359 

treatment  and  antidotes I-  370 

trouble  ^th  digestion !•  363 

ai'senious  acid,  "  Rough  on  Eats  " !•  356 

arsenious  oxide,  white  arsenic I-  356 

poisonous  symptoms !•  357 

Maybriek  case I-     357,  369 

properties  of !•  35& 


copper 


I.     404 


antidotes  and  treatment I-  407 

cooking  utensils  of I-  404 

cupric  sulphate I-  406 

dangerous  and  fatal  doses I-  407 

extraction  of,  fi'om  the  tissues 1-  408 

oceiu'rence  of,  in  natiu'e I-  404 

properties  of I-  404 

tests I-  407 

toxicology !•  404 

verdigris !•  40  < 

halogens  and  their  salts !•  333 

bromine I-  334 

potassium  bromide I-  334 

chlorine I-  333 

potassic  chlorate *•  !•  333 

symptoms I-  333 

iodine !•  335 

potassium  iodide I-  336 

iron !•  413 

fen-ic  chloride I-  413 

effects  iipon  man I-  413 

fatal  dose I-  413 

post-mortem  appearances I-  413 

ferrous  sulphate,  green  vitriol I.  413 

tests  for  iron I-  414 

lead I-  391 

acute  poisoniug I-  392 

post-mortem  appearances I-  393 

sjTnptoms I-  393 

time  of  death I-  393 

treatment I-  393 

cause  of  death I-  395 

chronic  poisoning I-  394 

blue  line  on  gums I-  394 

intestinal  pains,  colica  pictorum I.  394 


INDEX.  719 

PAGE 

Poisons,  Inorganic.     Lead,  chronic  poisoning : 

symptoms I.  394 

excretion  of  lead I.  395 

liow  introduced  into  system I.  391 

location  in  tissue I.  395 

properties  as  a  poison I.  391 

separating  lead  from  tissues I.  396 

tests I.  395 

mercury I.  396 

calomel,  mereurous  chloride I.  400 

chloride  and  bichloride I.  400 

fatal  dose  of I.  401 

post-mortem  ai)pearances I.  401 

time  of  death I.  401 

treatment  for I.  401 

chronic  jioisoning I.  398 

corrosive  sublimate,  mercuric I.  400 

effects,  physiological  and  poisonous I.  397 

elimination  of  poison I.  400 

external  poisoning I.  402 

mercurial  hysteria I.  399^ 

other  irritant  compounds  of I.  401 

separation  from  the  tissues I.  403 

tests  for I.  402 

mineral  acids I.  330 

aqua  f ortis I.  330 

boraeic  and  boric  acid I.  332 

chromic  acid,  chromic  anhydi-ide I.  331 

potassic  dichromate I.  332 

hydrochloric  acid I.  329 

distinction  from  other  acids I.  330 

muriatic  acid I.  329 

nitric  acid I.  330^ 

poisoning  by  fumes  of I.  331 

oil  of  vitriol I.  329 

sulphiu'ic  acid I.  326 

external  application I.  328 

post-mortem  examination I.  328 

symptoms I.  327 

tests I.  328 

treatment I.  327 

phosphorus I.  336 

dangerous  and  fatal  doses I.  339 

poisoning  by  vapor  of I.  339^ 

necrosis  of  jav^'  from I.  339 

vs.  atrophy  of  liver I.  338 

post-mortem  changes I.  338 

properties,  physiological I.  336 

poisoiious I.  337 

symptoms I.  337 

tests I.  340 


720  IXDEX. 

PAGE 

Poisons,  Inorganic.     Phosphorus : 

time  of  death I.  338 

treatment  and  antidotes I.  338 

silver I.  411 

argentic  nitrate I.  412 

chronic  poisoning  by I.  412 

tests I.  412 

tartar  emetic I.  342 

chronic  cases  of  poisoning  by I.  344 

dangerous  and  fatal  doses I.  344 

elimination  of I.  345 

physiological  effects,  external I.  342 

internal I.  343 

poisonous  effects  of  I.  343 

post-mortem  appearances I.  344 

Pritchard  case I.  343 

prognosis I.  344 

sjonptoms , I.  343 

times  of  death I.  345 

zinc I.  409 

chloride I.  409 

in  canned  vegetables I.  41 1 

internal  administration I.  410 

post-mortem  appearances I.  411 

sulphate,  white  ■^'itriol I.  409 

tests I.  411 

Poisons,  Organic I.  415 

alkaloidal I.  415 

aconite  and  aconitine I.  421 

detection  of  the  poison I.  423 

in  the  contents  of  the  stomach I.  423 

in  the  tissues I.  423 

fatal  quantity I.  422 

period  when  fatal I.  422 

post-mortem  appearances I.  422 

properties I.  421 

symptoms I.  421 

tests I.  423 

treatment I.  422 

aeonitin,  aconitina,  and  aconitia I.  421 

aconitum  f erox I.  421 

aeonitum  Fischeri I.  421 

aconitum  Napellus I.  421 

monk's-hood I.  421 

wolf's-bane I.  421 

atropine  and  belladonna I.  424 

atropin,  atropia,  atropa  belladonna,  deadly  nightshade I.  424 

detection  of  the  poison I.  426 

in  the  contents  of  the  stomach I.  426 

in  the  tissues I.  427 

fatal  cpiantity I.  424 


INDEX.  721 

PAGB 

Poisons,  OlinANic.     Alkaloidal,  atropine  and  belladonna  : 

period  when  fatal I.  424 

post-mortem  ai)pearaiiceH I.  425 

properties I.  424 

symptoms 1 .  424 

tests I.  425 

physiological I.  425 

Vitali's I.  426 

Wormley's I.  426 

treatment I.  425 

brucine  (synonyms,  Ijrueiu,  hnicia) I.  460 

symptoms  and  tests I.  460 

cocaine I.  428 

cocatannic  acid I.  428 

detection  of  tlie  poison I.  430 

erytliroxylon  coca I.  428 

fatal  quantity I.  429 

period  when  fatal I.  428 

post-mortem  appearances I.  429 

properties I.  428 

symptoms I.  428 

tests I.  429 

ferric  cliloride I.  429 

odor T.  429 

permanganate I.  429 

physiological I.  429 

treatment I.  429 

colchicum  and  colcliicine  (synon^Tns,  colcliicin,  colchicia,  colchicina). .  T.  430 

active  princi^jle  of  meadow  saffron I.  430 

detection  of  the  poison I.  432 

fatal  quantity I.  431 

period  when  fatal I.  430 

post-mortem  appearances I.  431 

properties  of  the  alkaloid I.  430 

resistance  to  putrefaction I.  432 

symptoms I.  430 

tests I.  431 

Mandelin's I.  431 

nitric  acid I.  431 

physiological I.  432 

Zeisel's I.  431 

treatment I.  431 

color-reactions  of  alkaloids  (jilate) I.  415 

composition I.  415 

conium   and  coniine  (synonyms,  eoniin,  conine,  conia,  conicine,  and 

conicina) I.  432 

active  prineiiile  of  hemlock I.  432 

detection  of  the  poison I.  434 

fatal  quantity I.  433 

pei'iod  when  fatal I.  433 

post-mortem  appearances I.  433 


722  IXDEX. 

PAGE 

Poisons,  Oegaxic.     Alkaloidal,  eonium  and  coniine  : 

properties  of  the  alkaloid I-  433 

symptoms !•  433 

tests I-  433 

alloxan I-  434 

bTityrie  acid I-  434 

hydroeliloric  acid I-  433 

odor I-  433 

treatment I-  433 

gelsemium,   gelsemine,   and   gelsemie    acid   (synonyms,   gelsemin  and 

gelsemia) !•  434 

active  principle  of  yellow  jasmine I-  434 

detection  of  the  poison I-  436 

gelsemie  acid  in  the  stomach I-  436 

gelsemine  in  the  stomach  and  in  the  tissues I.  437 

fatal  quantity I-  435 

period  when  fatal I-  435 

post-mortem  appearances I-  436 

properties  of I-  435 

gelsemie  acid !•  436 

gelsemine !•  436 

symptoms I-  435 

tests  for  gelsemie  acid !•  436 

fluorescence • !•  436 

nitric  acid  test I-  436 

sulphuric  acid  and  ammonia  test I-  436 

tests  for  gelsemin , !•  436 

nitric  acid  test !•  436 

oxidation  test I-  436 

treatment I-  435 

hyoseyamus  and  stramonium I-  427 

active  principle  of  datm-a  stramonium I-  42  / 

hyoscyamine,  hyoscine,  hyoseyamus  niger,  henbane I-  427 

isomer  of  atropine I-  427 

mydriatic  alkaloids I-  427 

symptoms I-  427 

tests I-  428 

niix  vomica  and  strychnine  (sjTionyms,  strychnin,  strychnia) I.  447 

chemical  properties  of  strychnine I-  44  < 

detection  of  the  poison I  451 

crystals  from  stomach I-  457 

detection  after  long  periods I-  459 

in  the  contents  of  stomach I-  456 

in  the  tissues I-  458 

quantitative  determination I-  4;)8 

diagnosis I-  449 

elimination I-  459 

failure  to  detect I-  459 

fatal  quantity I-  450 

period  when  fatal !•  450 

post-mortem  ax>pearances !•  451 


INDEX.  723 

PACK 

Poisons,  OKfiAXif.     Alkaloid,  almix  voniicii  ,iud  stiyehnine  : 

seed  of  strychiios  mix- vomica I.  447 

symptoms  of  poisoning  by I.  44S 

tests I.  4r>l 

color  test I.  A-^t'l 

crystals  of  strychniiic  eliromate , I.  45.") 

physiological  test I.  4.')G 

taste I.  4')! 

treatment I.  450 

opium  and  morpliinc I.  439 

alkaloids  contained  in  opium I.  439 

codeine I.  443 

meeonie  acid I.  440 

nareeine I.  440 

nareotine I.  439 

papaverine I.  440 

thebaine I.  440 

detection  of  poison I.  443 

in  contents  of  stomach I.  443 

in  contents  of  filter  for  meeonie  acid I.  444 

in  contents  of  filter  for  morphine I.  444 

in  crystals  of  morphine  from  stomach I.  44.") 

in  the  tissues I.  440 

diagnosis I.  441 

failure  to  detect I.  44(5 

fatal  quantity I.  441 

period  when  fatal I.  441 

pharmaceutical  preparations I.  440 

Magendie's  solution I.  440 

post-mortem  appearances I.  442 

properties  of  morphine I.  440 

symptoms ; I.  440 

tests  for  nieconic  acid I.  442 

ferric  chloride I.  443 

lead  acetate I.  443 

tests  for  morphine I.  442 

iodic  acid I.  443 

ferric  chloride I.  442 

nitric  acid I.  442 

sulpho-molybdic  acid I.  443 

treatment I.  441 

symptoms  produced  in  case  of  poisoning I.  417 

detection I.  418 

post-mortem  appearances I.  418 

treatment I.  417 

tobacco  and  nicotine  (s.vnonyms,  nicotin,  nicotia,  nicotina) I.  437 

active  principle  of  Nicotiana  Tahaciim I.  437 

detection  of  the  poison I.  439 

fatal  quantity I.  438 

period  when  fatal I.  438 

post-mortem  appearances I.  438 


724  INDEX. 


PAGE 


Poisons,  Organic.     Alkaloidal,  tobacco  and  nicotine  : 

properties  of  the  alkaloid I.  437 

resistance  to  putrefaction I.  43& 

symptoms I.  437 

tests I.  438 

liydi-ocliloric  acid I.  438 

iodine I.  439 

mercuric  chloride ' I.  438 

physiological I.  439 

treatment   I.  438 

veratmm,  verati-ine,  and  jervine I.  460 

active  principle  of  hellebore   I.  462 

detection  of  the  poison I.  462 

in  contents  of  stomach I.  462' 

in  tissues I.  463 

fatal  dose I.  461 

period  when  fatal I.  46] 

post-mortem  aj)pearances I.  461 

properties  of  the  alkaloid I.  461 

sjTuptoms  of  poisoning  by I.  461 

tests  for  jervine I.  462 

tests  for  veratrine I.  462 

hydi'ochloric  acid I.  462 

physiological I.  462 

suljjhuric  acid I.  462 

treatment I.  461 

not  alkaloidal I.  463 

camphor I.  472 

post-mortem  appearances I.  473 

symptoms I.  472 

treatment I.  473- 

eantharides  or  Spanish  fly I.  472 

detection  of  poison I.  472 

post-mortem  appearances I.  472 

symptoms I.  472 

treatment I.  472 

carbolic  acid  (sjoionyms,  phenol,  phenyl  hydrate) I.  469 

detection  of  poison I.  472 

fatal  quantity I.  472 

period  when  fatal I.  472 

post-mortem  appearances I.  472 

symptoms I.  470 

tests,  bromine I.  471 

ferric  chloride I.  471 

hj^jochlorite I.  471 

chloral,  chloral  hydi'ate I.  468 

detection  of  poison I.  469 

fatal  period I.  469 

fatal  quantity I.  469 

post-moi-tem  appearances I.  469 

resistance  to  decomposition I.  469 


iM>i:x. 


no 


I'.vriK 


Poisons,  Ok<;anic.     Not  iilkaloidal,  diloral,  Vliloral  liydrate  : 

symptoms I.  4(iH 

tests I.  4()'J 

tveatiiifiit I.  4(j!> 

chlorofoi'in 1 .  4()(> 

detection  t^^  jioisoii I.  4(i>i 

resistance  to  dcc<)iii]p()sitii)ii I.  408 

(«)  taken  as  a  li<|ui<l  liy  tlic  iiioutli I.  4(i(> 

fatal  (jiiaiitity I.  4G(> 

period  wlieii  fatal I.  4(50 

])ost-inortciii  appearances I.  407 

symptoms I.  4t)f> 

treatment I.  40G 

{h)  taken  as  a  vapor  liy  the  lungs I.  407 

fatal  period I.  4()7 

fatal  quantity T.  4()7 

post-mortem  appearances I.  407 

symptoms I.  407 

treatment I.  407 

tests I.  407 

Coccitlits  JiKlifiis I.  47iJ 

detection  of  the  poison I.  473- 

picrotoxin I.  47;i 

post-mortem  appearances I.  47:i 

symptoms I.  473 

treatment I.  473 

croton  oil I.  4  71 

detection  of  t  he  poison I.  471 

post-mortem  appearances I.  471 

symptoms I.  471 

treatment I.  471 

digitalis,  foxglove  (synonyms,  digitalin,  digitonin,  digitoxin,  digitalein, 

toxiresin) I.  4t)3 

detection  of  the  poison I.  4(i5 

fatal  quantity. I.  404 

period  when  fatal I.  404 

post-mortem  appearances I.  404- 

resistance  to  putrefaction I.  405 

symptoms I.  403 

tests :  Grandeau's I.  404 

Lafon's I.  4(5.> 

treatment I.  475 

Poisons,  Ptomaines,  and  other  putrefactive  products I.  475 

animal  alkaloids I.  475 

distinctive  color-reactions I.  487 

poisons  formed  during  putrefaction I.  491 

cancroin I.  492 

cholin I.  492 

ethylendianiin  and  ethylidendiamin I.  491 

fugin I.  492 

gadinine I.  492 


72G  INDEX. 

PAGE 

Poisons,  Ptomaines,  etc.     Poisons  formed  during  piitref action : 

isoamylamine I.  491 

methj'lguanidine I.  49  L 

mydaleine I.  492 

mydatoxine I.  492 

mytilotoxine I.  492 

neiirine I.  492 

patoammiue I.  491 

ptomo-muscarines I.  492 

susotoxine T.  492 

tetanine,  tetanotoxine,  spasmotoxine,  and  tetanus  toxalbumins I.  491 

trimethylendiamiu I.  491 

typhotoxine I.  492 

tyi'otoxicon I.  492 

poisons  formed  in  decomposing  tissue  in  tlie  presence  of  arsenic I.  490 

acquetta  di  Perugia I.  490 

aqua  toffana I.  490 

purity  of  reagents I.  476 

putrefactive  products I.  487 

hydroparacumaric  acid  (para-oxyplienyl-propionie  acid) I.  489 

indol,  indoxyl  (indirubin  and  indigo-blue) I.  489 

parakresol I.  490 

para-oxyphenyl-acetic  acid I.  490 

plienol I.  490 

sliatol  (methyl  indol),  skatol-acetic  acid I.  489 

putrefactive  products  resembling  the  vegetable  alkaloids I.  477 

eolchicine-like  products I.  483 

delphinine-like  products I.  482 

staphis  agria I.  482 

■digitaline-like  products I.  482 

experiments  on  effects  of I.     485-487 

morphine-like  products I.  484 

nicotine-like  products I.  479 

;stryclinine-like  products I.  480 

pellagra I.  480 

veratrine-like  products I.  481 

tests  for  (see  under  each  poison). 

Poppy,  papaverine,  papaver  somniferum I.     439,  440 

PoRPHYRiDiUM,  spores  of,  in  microscopical  examination  of  blood-stains I.  170 

Post-mortem  Examinations I.     25,  57 

accepted  period  of  life I-  58 

authorities I.  57 

autopsies  and  coroners'  inquests I.     27,  57 

Iblood  (of) I.     37,  43,  88 

Islood-stains  (of) I.  29 

contusions  (of) I.  32 

ci'iminal  assaults I.  33 

rape  followed  by  murder I.  29 

seminal  stains I.  29 

decomposition  and  putrefaction  (see  Death)  I.     35,  99-107 

determination  of  age I.     56,  C4,  60 


INDEX.  Til 

PAGE 

Post-mortem  Examinations.     Determination  of  age  : 

antlii'opologieal  aids  to I.       59 

as  determined  by  skeleton   I.     56,  08 

determination  of  identity  (see  Death  and  Identity) I.     30,  '.i'l,  59 

cases  of  mistaken  identity I.       .'5(J 

Tielibornc  claimant I.       71 

Whitecliapel  murders I.     01,  75 

determination  of  manner  of  death  (see  Deatli) I.     20,  58 

by  asphyxiation ' I.     120 

drowning I.       88 

electricity I.     134 

hanging  and  strangulation I.     33,  110 

poison I.     33,  97 

starvation I.     134 

suicide I.     32,  88 

violence ■ I.     32,  47,  58 

finger-marks I,     32 

government  regulation  of I.     27,  57 

in  France  and  Germany I.       57 

need  of  reform I.       26 

injuries  on  genitalia I.       33 

contusions  and  lividities I.     32,  35 

medico-legal  inspections I.     25,  57 

importance  of I.     26,  57 

methods  and  safeguards I.     26,  95 

classification  of I.     26 

■order  of I.     27,  37 

appearances  in  chloroform  narcosis II.     590 

bodies  advanced  in  putrefaction I.       53 

of  children I.       51 

examination  of  abdomen I.       42 

bladder I.       48 

bones I.       55 

brain I.     39,  40 

female  organs I.       48 

signs  of  abortion II.     475 

heart I.       44 

kidneys  and  spleen I.       4S 

liver I.       50 

spinal  cord 1.       40 

stomach  and  diiodenum I.       49 

thorax I.     42,  43 

external  examination  of  body I.       32 

contusions,  iinger-marks,  wounds I.     32,  33 

identity  of  body I.       30 

inspection  of  natural  orifices I.       33 

corrosive  poisons,  strangulation,  epilepsy,  criminal  assaults I.       33 

internal  examination I.       35 

instruments,  proi)er  time  for T.       36 

is  life  extinct  ? I.       27 

position  of  bodj- I.       29 


728  INDEX. 

PAGF- 

PosT-JiORTEJi  Examinations.     Order  of : 

post-mortem  lividities,  ecchymoses,  and  decomposition I.  35- 

smToundiug  circumstances  and  objects I.  28- 

suspended  animation I.  88 

temperature  of  body I.       o-l,  90 

purpose  of I.  25 

safeguards  to  be  observed I.  26 

tables :  of  details  to  be  noted I.  75 

of  hair I.  74 

of  skeleton I.     64,  68 

of  teeth I.  67 

of  weights  of  organs I.  50 

wounds I.     o2,  71 

edges  of I.  33 

gunshot,  search  for  bullet I.  47 

Garfield  case I.  47 

inflicted  during  life I.  33 

of  the  neck I.  32 

penetrating I.  32 

suicidal I.  32 

Potash I.  322 

Practice  of  Medicine,  what  constitutes  proof  of I.  602 

Prescription,  ownership  of I.  636 

Primary  Dementia  (see  Insanity) II.  1 09 , 

Professional  Confidences  of  physicians  and  surgeons I.  616 

Carlyle  Harris  case I.  625 

Progeny  of  the  insane  (see  Insanity  and  Heredity) II.  58 

Psychiatry II.  177 

Psychical  deafness  and  blindness II.  268 

Ptomo-muscarines I.  492 

Puerperal  Fever II.  457 

Puerperal  Insanity  (see  Insanity) II.  103 

Putrefaction  (see  Death  and  Post-mortem  Examinations) I.     99,  475 

Railway  Spine II.  307 

Rape II.  525 

actual  and  apparent  age II.  543 

age  of  consent I.     651 ;  II.  525 

coitus,  anatomical  changes  induced  by,  in  labia,  in  h^Tuen II.     527,  528 

conditions  indicating II.  526 

genital  discharges II.  537 

proof  of  presence  of  semen II.  535 

state  of  vaginal  wall  and  mucous  membrane II.  535 

venereal  diseases  communicated  in II.  536 

causes  of  infection  other  than  sexual  contact II.  537 

gonon-hea,  presence  of  gonoeoeci II.  536 

false  accusations  of II.  542 

for  blackmail II.  542 

the  result  of  illusions,  cases II.     211.  .342 

followed  by  murder I.  29 

force,  moral II .  540 

physical  evidences  of II.  539 


ISDKX.  7 -J  J 

pa(;k 

Rai'K,  fraud,  intercourse  accomplished  tlirouj^h II,     540 

lej^al  coiisideriitioiis II.     525 

sec'Oiuliiry  eonsequeiiees  of II.     544 

sexual  assault,  on  children I.     fi4!) ;  II.     54;i 

on  male  children II.     544 

states  of  hypnosis  and  autohyjjnosis II.     541 

non  compos  mentis 11.     543 

unconsciousness,  f!icilitatiii<^ II.     540 

Raptus  Mei.anchulicu.s II.     1  \y.i 

Realoak I.     ;j>i7 

Reflex  Action  (see  Insanity) II.     21,  29 

Recistratiox  of  physicians  and  surgeons I.     GOO 

Relations  of  medical  profession  to  life  insurance I.     514,  591 

Religious  Excitement  (see  Insanity) II.      51 

Representations  in  relation  to  insurance I.      498 

Residence  in  relation  to  insurance I,     560 

Responsibility,  Criminal II.     2i;j,  217,  245 

apiireciation  of  nature  of  acts II.     -'.VI 

case  of  People  rx.  Barber II,     2.'j;j 

criminal-law  definitions  of II.     217-220 

Coke,  Hale II.     217 

MeXaghteu  case II.     218 

delusions  as  a  defense  for  crime ■ II,     230,  234 

cases II.     235-241 

dementia  (accidental)  or  insanity II.     222 

ei)ilepsy II,     223 

lucid  intervals II,     222 

(natural)  or  idiocy II,     220 

cases II.     221 

partial  insanity II.     224 

total  insanity II.     222 

cases II.     225-231 

effects  of  mental  disease  upon  emotions  and  will II.     242,  251 

cases II.     243-253 

■  evidences  of  design II.     232 

impulse,  maniacal II.     250 

uncontrollable II.     44.  180,  191,  243 

cases II,     245-251 

moral  insanity II.     252 

eases II.     253-258 

motive  or  absence  of II.     234 

"right  or  wrong"  test IT.     228 

Responsibility  in  Civil  Cases II.     1(59 

of  children II.     1S4 

of  surgeon  for  malpractice TI.     573 

of  tlie  insane  (see  Insanity) II.     1 70 

Rheumatism  as  affecting  insurance I.     536 

RinoR  Mortis  (see  Death) , I.       93 

Rough  on  Rats I.     3.56 

Sadism II.     500 

Sanctity  of  the  Person  of  patients I,     632 


730  INDEX. 

PAGE' 

Saponification  (see  Death) I.     105- 

Satyriasis • 11.       50- 

Scalds  (see  Wounds) I.     288 

Scalp,  atheroma  of II.     GU9 

Selp-Mittilation  (see  Insaue  Impulse) II.       48 

Seminal  Stains I.     29,  184  ;  II.     536- 

Senile  Dementia II.     109 

Sensorielle  Verrucktheit II.     34 

Sepsis,  septica?mia I.     90  ;  II.     587 

Sex,  defective  sexual  organs II.     418,  422' 

medico-legal  importance  of  diseases  of  sexual  organs II.     425,  426- 

determination  of. II.     418 

hermaphrodism II.     418,  419 

cases  of II.     419-425' 

gynanders  and  androgyns II.     419 

menopause II.     435' 

menstruation,  normal  and  abnormal II.     43] 

puberty  and  attendant  phenomena II.     429 

Sexual  Impulses  (see  Insanity) II.       49 

Sexual  Irritation  (see  Insanityj '. II.       51 

Sexual  Perversion II.     48,  550^ 

anomalies,  congenital  and  acquired II.     552.  554 

bestiality II.     547 

contrary  sexuality II.     569 

eases  of II.     570 

education,  influence  of,  upon II.     554 

psychosexual  development II.     551 

erotic  f etichism II.     566- 

body  fetichism,  and  cases  of II.     567 

dress  fetichism,  and  cases  of II.     568,  569 

Lesbians II.       50- 

lust-min-der II.     561 

nymphomania II.       50' 

passivism II.     564 

pederasty II.     546 

pathognomonic  signs  of II.     546 

responsibility  of  perverts II.     545.  572 

sadism II.     560 

sat  jri'iasis II.       50' 

senile  attempt  at  rape,  and  cases  of II.     551 

dementia,  abnormal  sexuality  in II.     1 09 

sexual  anaesthesia II.     557 

hypersesthesia,  and  cases  of II.     557,  558 

jDaradoxia II.     555 

parfesthesia II .     555,  559 

sodomy II.     545 

English  common  law  on II.     545 

tribadism II.     547 

Sexual  Vigor,  exaggeration  of  (see  Insanity) II.       51 

Shock  (see  Traumatic  Neuroses) 11.     297,  303 

Silver,  argentic  nitrate I.     411 


ISDEX.  731 

I'AfiK 

SiMiLATiox  (^see  Feigned  Diseases) II.  444 

Slandkr  of  medical  injictitioiiers I.  G40 

Sleep,  condition  of  senn-conscionsness II.  51 

dreaming II.  ,")! 

drunkenness II.  '>\ 

rape  in II.  .■;4i) 

sorananibulism II.  ."il 

Soda I.  :ji2i» 

Sodomy  (see  Sexual  Perversion) II.  .145 

SOMN'AJIBILISM II.  51 

Spanish  Fly I.  472 

Spasmotoxine I.  4!H 

Spectroscope,  for  deterniining  blood-stains I.  142 

for  determining  luvmoglobin I.  1 44 

Stokes'  band I.  147 

Speech  Centers II.     24,  269 

Speech  Disturbaxces II.  270 

feigned 11.  410 

in  aphasia II.     259-296 

verbigeration II.  74 

Spermatozoa  (see  Seminal  Stains) I.  185 

Spontaneous  Combustion I.  133 

Stains,  blood  (see  Blood-stains) I.     29,  139 

seminal  (see  Seminal  Stains) I.     29,  184 

Staphis  Agria I.  4s2 

Starvation,  death  by I.  134 

baby-farming I.  ]  37 

Welsh  fasting  girl '. I.  137 

Sterility  (see  Genito-nrinarv  Diseases) II.  5(»3 

Stokes'  Band  (see  Spectroscope) I.  147 

Stramonium,  Datura I.  427 

Strangulation  (see  Death  and  Post-mortem  Examinations) I.     33,  116 

Strychnine,  strychnin,  strychnia I.  447 

Suffocation  (see  Death  and  Post-mortem  Examinations) I.     liiS-115 

and  insanity II.  45 

and  melancholia II.  192 

Suicide  (see  Wounds) I.  280 

as  affecting  insurance I.  .565 

as  aflfecting  testamentary  capacity II.  128 

by  carbolic  acid I.  88 

by  drowniing I.  1 28 

by  hanging  or  strangulation I.  116 

fantastic II.  48 

statistics  of,  in  New  York  for  1891 I.  352 

Surgeon,  measure  of  responsibility  of II.  57.} 

partnership  liability 11.  5S^ 

punishment  of II.     574,  582 

Surgical  Practice  and  Malpractice  : 

accessory  wound  diseases II.  7t>>9 

amputations II.  621 

anaesthetics,  administration  of II.  594 


732  ISDEX. 

PAGE 

Surgical  Practice,  etc.     Ana?stlietics,  administration  of: 

administration  of,  to  pregnant  women II.  600 

bromide  of  ethyl  (hydro bromie  ether) II.  603 

cause  of  death  from,  direct  and  indirect II.     595,  596 

chloroform  idiosyncrasy .II.  598 

dangerous  or  fatal  narcosis,  treatment  of II.  599 

defense  in II.  604 

■death  from II.  594 

post-mortem  appearances II.  596 

effects  of,  upon  kidneys II.  597 

■ether,  objections  to •. II.  600 

failure  to  produce  results II.  602 

nitrous  oxide II.  603 

aseptic  and  antiseptic  treatment II.  590 

accidental  wounds II.  593 

microorganisms II.  589 

precautions II.  593 

procedure II.  592 

common  mishaps  in,  special  or  regional  considerations :  abscess,  ampu- 
tation of  breast,  aneurism,  atheroma  of  scalp,  catheterization  of  Eu- 
stachian tubes,  cleft  palate,  embolism,  empyema,  extraction  of  teeth, 
gunshot  injuries,  harelip,  hemorrhage,  incisions  in  neck,  injuries  of 
head  and  neck,  intoxication  from  fibrin  ferment,  lacteal  fistula,  mas- 
toid disease,  sepsis,  tetanus,  thyi"oideetomy,  tonsilotomy,  tracheotomy, 

traumatic  delirium,  trephining,  tumors II.     584-614 

fractures  of  extremities II.  614 

eoutractiu'e  and  anchylosis II.  621 

deformities  following II.  614 

gangrene  following II.  617 

hip-joint  injuries  and  disease II.     618,  619 

resection II.  620 

tenotomies  and  myotomies II.  621 

genito-urinary  organs II.  625 

abscess  of  testicle,  castration,  catheterization,  circumcision,   extrava- 
sation of  urine,  hernia,  hydrocele,  hysterical  atony,  lithotomy-,  vesical 

calculus : II.     625-629 

improper  iutrodiietion  of  non-professional  into  case II.  580 

malpractice,  burden  of  proof  of II.  581 

contributory  negligence  in II.  581 

critei'ia  of II.  576 

defense  in II.  581 

definition  of '. II.  573 

errors  in  diagnosis  and  of  judgment II.  576 

experimental  surgery 11.  580 

gratiutous  services II.  578 

latest  methods  and  appliances II.  577 

liability  (criminal),  action  barred  by  recovery  for  services II.  583 

common-law  provisions II.  583 

measure  of  resjionsibility II.  573 

when  aseptic  principles  are  violated II.  591 

partnersliip  liability II.  583 


iM>i:.\.  7;;;] 

I>A(JK 

Surgical  PRAfTiCE,  etc.     Malpvactico,  l>ui(l<ii  of  inoof  of,  etc. : 

pecuniary  dauiages II.  •'JS2 

unexpected  and  unfortunate  residts  of  opercations II.  'tT.') 

unusual  enierj^fncies II.  .'iT" 

operations,  abdomen  and  iiel vis II.  (Vl'l 

disturbances  follo\vin<^ II.  <>-•"> 

procedure  not  rcslrictcd II.  'liH' 

response  to  cull II.  "iTT 

warranty  to  ciiic II.  ;")78 

Survivorship I.  ii.'M 

case  of  Underwood  vs.  Win<; I.  L'3G 

SU-SOTOXINE I.  492 

Suspended  Ani.mation I.  88 

Symphyseotomy II.  459 

Syncope I.  88 

Syphilis II.  509 

Tables  and  Statistics  : 

accidental  deaths  in  New  York  City,  1 870-91 I.  352 

antesthetics,  mortality  from  use  of II.     379,  GOl 

Baleli,  experiments  on  effects  of  gunshot  wounds I.  254 

blood-corpuscles,  measurements  of I.  173 

comparative  actual  and  computed  ratea  of  mortality I.  511 

nu>rtality  in  tubercular  and  heart  diseases I.  512 

deaths  from  arsenical  poisoning I.  351 

consumption  in  New  York  City  and  in  Mutual  Life  Insurance 

Co I.  530 

poisoning  in  England  and  Wales,  1883-87 I.  351 

details  to  be  noted  in  examining  into  identity I.  75 

hair,  according  to  race  characteristics I.  19G 

insanity,  classification  of,  by  Hamilton II.  5G 

Maudsley II.  57 

Von  Krafft-Ebing II.  55 

extent  of  hallucinations,  etc II.  34 

symptoms  favorable  and  the  reverse II.  64 

mortality  in  diffei-ent  occupations I.  557 

(relative)  of  intemperate  persons I.  550 

railroad  accidents II.  307 

stature  :  Orfila's-  method I.  G^ 

Sue's  method I.  G9 

suicides  in  New  York  City  in  1891 I.  352 

teeth I.  G7 

weights  of  organs  of  human  body I.  50 

Tartar  Emetic I.  342 

Tattooing I.     72,  202 

Teeth,  extract  ion  of,  mishaps  occurring  in II.  Gil 

identification  by I.  195 

post-mortem  examination  of I.     56,  G7 

Temperature  of  body  at  time  of  death I.  34 

Tenotomies II.  621 

Tests  for  blood I.     157,  1()2 

signs  of  death I.  9b 


734  INDEX. 

PAGE 

Tests  for  blood,  suspected  blood-stains I.     152,  157 

aconite,  etc I.     423 

antimony I.     347 

arsenic !•     372,  374 

belladonna  and  atropine  with I.     425 

Vitali's  method I.     426 

Wormley's  method I.     426 

carbolic  acid  with  bromine,  ferric  chloride,  hypochlorite I.     471 

chloral !•     469 

chloroform I-     469' 

cocaine  with  ferric  chloride,  odor,  permanganate,  physiological I.     429 

colchicum  with  Mandolin's,  nitric  acid,  physiological,  Zeisel's I.     431,  432 

coniine  with  alloxan,  butyric  acid,  hydrochloric  acid,  odor I.     433,  434 


copper 


I.     407 


digitalis  with  Grandeau's,  Lafon's I.  465 

gelsemic  acid  with  ammonia,  fluorescence,  nitric  acid,  sulphuric  acid. .  I.  436 

gelsemine  with  nitric  acid,  oxidation I.  451 

iron I.  414 

jervine !•  462 

lead I.  ♦  395 

meconic  acid  with  ferric  chloride,  lead  acetate I.  443 

mercury I-  402 

nicotine  with  hydrochloric  acid,  iodine,  mercuric  chloride,  physiolog- 
ical   I.     438,  439 

opium  and  morphine  with  ferric  chloride,  iodic  acid,  nitric  acid,  sulpho- 

molybdic  acid I-  442 

silver I-  412 

strychnine  with  color,  crystals  of  strychnine  chromate,  physiological, 

taste I.  451 

veratrine  with  hydrochloric  acid,  physiological,  sulphuric  acid I.  462 

zinc I.  409 

Testamentary  Capacity II-  115 

as  affected  by  alcoholism II-  123 

delusions II-  118 

dementia II-  116 

disease II-  120 

eccentricity II-  119 

epilepsy II.  1 22 

hypnotism II-  1 27 

old  age II-     116,  117 

senile  dementia II-  116 

suicide II-  128 

proof  of  a  disposing  mind II-  115 

German  decisions  regarding II.  115 

what  constitutes II-  115 

Tetanine,  tetanotoxine,  spasmotoxine,  tetanus  toxalbumins I.  491 

Tetanus  as  a  mishap  in  surgical  practice II-  585 

Thebaine I-  440 

Theory  (legal)  of  criminal  responsibility II-  217 

Thyroidectomy 11-  612 

Tobacco I.  437 


IMJEX.  7;}0 

PAtiE 

ToNsiLiTis  as  iiffet'ting  insurance I.     b'M 

Torts  by  tlie  insane II.     ]  43 

Toxic  Insanity II.     liOo 

alcoliolism II.     'l^)'^ 

cases II.     1^(1(5 

offenses  duo  to II.     Jii.") 

physical  and  psychic  sjnnptoms II.     205,  2(iG 

cocaine  habit II.     209 

morpliine  habit II.     207 

offenses  due  to II.     208 

symptoms  of II.     207 

ToxiKKsiN I.     463 

Tkacheotomy II.     612 

TuAUMATK'  Deliuitm  as  a  niisluip  in  surgical  practice II.     584 

Traumatic  Insanity  (see  Insanity) II.     1 05 

Traumatic  Neuroses II.     297 

tetiology JI.     305 

age  when  most  liable  to II.     305 

ataxiagrauT II.     315 

bibliography  and  index II.     352-360 

classification  of  disorders  following  injury II.     303 

concentration  of  popidation  as  aft"ectiug II.     306 

condition  at  time  of  injury II.     306 

subsequent  to  injury II.     307 

definitions  and  sjTionyms II.     297 

diagnosis  and  prognosis II.     333.  334 

feigned II.     402 

grave  traumatic  neurosis,  and  cases  of II.     331,  332 

history  of II.     298 

hysteria  (traumatic) II.     305,  334 

cases  of,  in  a  woman  cataleptic II.     350 

with  violent  tremor II.     348 

pathology  of II.     351 

prognosis  of II.     350 

susceptibility  in  age,  race,  and  sex II.     335 

symptoms  of II.     336 

metliods  of  examination  and  diagnosis II.     321.  322 

mooted  points II.     300 

neurastlienia  (traumatic) II.     305 

pathology  of II.     330.  334 

previous  condition  of  health II.     306 

sex  most  liable  to II.     305 

shock  and  concussion II.     303 

statistics  of  railroad  accidents II.     307 

symptoms II.     307 

neurasthenia  (railway  spine),  spinal  irritation,  hypochondriacal  neu- 
roses, unusual,  special,  muscular  and  motor,  sensory,  \4sual,  hear- 
ing, laryngeal,  vasomotor,  pulse,  bladder  and  kidneys II.     307-320 

tests II.     322 

for  nerves  and  muscles,  traiunatic  reaction,  sensory  and  visual  s\nnp- 

toms II.     322-32£> 


736  INDEX. 

PAGE 

Trejxor,  feigned -11.  402 

Trephining n.  609 

Tribadism 11.  547 

Trichomonas  Vagina I.  185 

Trimethtlendiaaiin I.  491 

ToioRS  in  the  neck 11.  613 

of  abdomen  and  pelvis II.  622 

retropharyngeal II.  612 

Ttphojiania II.  103 

Typhotoxine I.  492 

Tykotoxicon I.  492 

Uncontrollable  Impulse  (see  Insanity) II.  242 

views  of  the  courts  in  regard  to , II.  244 

I'ndue  Influence II.  125 

TTntrofessional  Conduct I.  599 

I7n.sox:ndn'ess  of  Mind , II.  113 

degi-ee  of II.  130 

Urethritis II.  505 

Tasa  Deferentia II.  504 

Teratrum,  vera  trine I.  460 

Verbigeration 11.  74 

Verdigris I.  407 

Yerrucktheit n.     34,  89 

Vitriol,  green I.  413 

oil  of I.  329 

thi-owing I.  289 

white I.  409 

Volition n.  28 

disturbances  of II.  48 

suspended 11.  51 

Waiver  in  professional  relations  of  physicians  and  siu'geons I.  626 

Warranties  in  relation  to  insiu-ance I.  498 

Weapons  (see  Wounds) ; I.  275 

Weight  of  brain I.  20 

Wills  (see  Testamentary  Capacity). 

French  laws  regarding II.  266 

made  in  extremis II.  116 

of  di-unkards ' II.  123 

insane II.  170 

suicides II.  128 

Witnesses,  the  insane  as II.  137 

Wolf's-bane I.  421 

Wounds  (see  Blood-stains,  Death,  and  Post-mortem  Examinations). 

affecting  special  parts I.  296 

abdominal  walls I.  308 

bladder I.  314 

chest I.  305 

diaphragm I.  308 

effusions  from  violence  or  disease I.  299 

facial I.  303 

genitals I.  315 


INDEX.  737 

PAGE 

WorxDs.     AlVct'tiiig  si)eciiil  parts: 

lu-ad I.  29G 

heart I.  :Ji»7 

intestines I.  310 

involving  cavities I.  LMS 

kidneys I.  310 

liver ; I.  :J09 

neck I.  304 

spine I.  300 

fractures  of I.  3(11' 

injuries  to  spinal  cord I.  302 

stomach I.  310 

vertebrae,  dislocation  of I.  301 

blood  npon  weapons I.  L'To 

Steeubergli  case   I.  275 

blood-stains,  evidence  from I.  274 

bullets,  sliot,  or  otlier  substances  in  wounds I.  276 

burns  and  scalds I.  288 

as  cover  for  crime I.  287 

blisters I.  288 

bodies  destroyed  by  fire .  I.  289 

boiling  oil  and  sugar I.  287 

boiling  water I.  288 

electricity  by II.  371 

contusions  and  eechymoses I.  244 

concussion I.  287 

discolorations I.  247 

extravasation I.  298 

from  sand-bags I.  24.") 

of  abdomen I.  24.^ 

of  head I.  297 

on  living  or  dead  body I.  245 

pseudo-eechymosis I.  24(5 

corrosive  liquids I.  289 

danger  of I.  258 

defined I.  243 

dirt,  grass,  and  similar  substances  in I.  277 

dislocations I.  294 

effusion  from  violence  or  disease I.  299 

evidence  of  weapons  and  other  articles I.  259 

Billings  case   I.  263 

Briggs  case I.  262 

Budge  case I.     249,  259,  273,  277 

did  person  move  after I.  295 

Fort  Edwards  case I.  269 

from  blood-stains I.  272 

Hughes  case I.  270 

Klock  case I.  268 

Mallon  case I.  271 

manner  in  which  blood  flows I.  273 

Mechanicsville  case I.  268 


738  INDEX. 

PAGE 

"Wounds.     Evidence  of,  etc : 

position  of  body -  I.  294 

Weston  case I.  260 

extravasation  of  blood  from  a  blow I.  298 

fractures I.  290 

cause  of I.  291 

from  blows I.  247 

of  bones  of  skull I.  293 

of  ribs I.  292 

of  spine I.  302 

spontaneous I.  291 

gunshot  (see  Bullets) I.  252 

experiments  by  Dr.  Baleli I.     254,  257,  266,  267 

Heigham  case I.  254 

loss  of  lead  by  ball I-  252 

made  by  shot-guns. I.  253 

marks  of  discharge I.  254 

self-inflicted I.  258 

incised  by  cutting  instruments I.  247 

blood-marks  from I.  248 

Budge  case I.     249,  259,  273,  277 

made  immediately  after  death I.  249 

signs  of  healing I.  248 

lacerated I.  250 

O'Shea  case I.  251 

position  of  weapon,  clothes,  or  body I.  277 

post-mortem  examination  of I.     32-47 

relation  of  medical  witness I.  315 

severity  of I.  258 

suicide I.  280 

Captain  Colvocoresses  case I.  282 

determination  between  suicid^  and  accident I.  284 

weapons,  blood  upon I.  275 

Budge  case v I-     249,  259,  273,  277 

evidence  of I.  249 

hair  upon I.  276 

position  of I.  277 

Thompson  case I.  278 

where  more  than  one I.  279 

Bruin  ease I.  281 

Shattuck  case I.  281 

wound  diseases,  accessory 11.  588 

microorganisms IT.  589 

Zinc,  zinc  chloride I.  409 


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